I.
German Lopez of Vox writes that “America’s criminal justice system has in many ways become a substitute for the US’ largely gutted mental health system”.
He says that starting in the 1970s the US “began locking up a lot more people”, and “at the same time, the country pulled back and defunded its public mental health system”. He admits that “this wasn’t, at the time, totally malicious”, but then says it “left the criminal justice system as the only system that can respond to people with mental illness.”
He concludes that as a result, “the number of people with mental illness in prisons/jails outnumber those in state hospitals 10 to 1.” The apparent (though unstated) conclusion is that defunding the big state mental hospitals was a mistake and we need to bring them back so that the mentally ill in state hospitals once more outnumber those in prison.
Lopez seems to be working off a model where there is a population of mentally ill people who can’t make it in normal society, and so will inevitably end up either in a long-term mental hospital or a prison. Since mental hospitals are good places where people get treatment, and prisons are bad places where people get punishment, we should “catch” these mentally ill people before they end up in prison so that they can be in nice hospitals instead.
Needless to say I disagree with pretty much every part of this assessment.
II.
Between all of this talk of “the tragic collapse of America’s public mental health system” and “the US’s largely gutted mental health system” and “the country pulled back and defunded its mental health system” and so on, you might get the impression that less money is being spent on mental health. This is not really true. The share of GDP devoted to mental health is the same as it was in 1971, although this looks worse if you compare it to rising costs in other areas of health care. There hasn’t been a “gutting of the mental health system”, there’s been a shift from long-term state-run mental hospitals to community care. It hasn’t “left the criminal justice system as the only system that can respond to people with mental illness”, it helped create an alternate and less restrictive system of outpatient psychiatry. In my opinion, this was a positive development, and the share of mentally ill people in prison is not an argument against it. Let me explain.
“Mentally ill people in prison” conjures up this lurid image of psychos who snap and kill their families, followed by “well, what did you expect leaving a person like that on the street?” The reality is more mundane. There are lots of mentally ill people in prison because there are lots of mentally ill people everywhere. Remember, 20% of the population qualifies as mentally ill in one sense or another. If a depressed guy sells some marijuana and gets caught, he is now a “mentally ill person in prison”.
There are disproportionately many mentally ill people in prison partly because people’s illnesses lead them to commit crimes, but mostly because some of the factors correlated with mental illness are the same factors correlated with criminality. Poverty? Check. Neighborhood effects? Check. Genetic load? Check. Education? Check. IQ? Check. Broken families? Check. Drug abuse? Definitely check. The factors that gave that pot dealer depression might be the same factors that drove him to sell pot instead of becoming an astronaut. Treating the depression might help a little, but it’s not guaranteed to keep him on the good side of the law.
In my model, the overwhelming majority of mentally ill people can live okay lives outside of any institution, hopefully receiving community care if they want it. If they commit crimes they will go to prison just like anyone else; if not, we should hardly be clamoring to bring back the often-horrifying state-run mental hospitals and lock them up there.
So when we talk about the number of mentally ill people in prison, we should be trying to distinguish between Lopez’s model and mine. That means asking: exactly how mentally ill are we talking about here?
III.
Lopez’s source for the claim that “ten times more mentally ill people are in prisons than hospitals” is a report by the Treatment Advocacy Center – note the less-than-neutral name. Where Lopez uses the phrase “mental illness”, TAC uses the phrase “severe mental illness” and defines it in two ways. For people in state prisons, they define it as reporting at least one psychotic symptom, and say 15% of people met their criteria. For people in county jails, they define it as meeting criteria for a depressive, bipolar, or psychotic illness, and say 15% of people met their criteria (they later arbitrarily increase that number to 20% because they feel like the survey might have undercounted).
No no NO. First, “psychotic” is not the same thing as “severely mentally ill”. Some people are severe but not psychotic – for example, a suicidally depressed person. Others are psychotic but not severe – for example, someone who hears a voice whispering her name but shrugs it off. Describing a survey that shows 15% of people as admitting one symptom of psychosis as showing 15% of people are severely mentally ill is really sketchy.
The prison survey provides a perfect example. It looks like the prisoners were asked fixed questions about their symptoms, and I think the exact screening instrument was just this survey, which has four relevant questions: “Can anybody else control your brain or thoughts?”, “Do you ever hear voices other people don’t hear?”, “Do you ever see something that other people tell you isn’t real?” and “Do you ever think anyone (other than correctional staff) is spying on you or plotting against you?”
Unfortunately, these kinds of surveys are really weak. I’m doing a study about this now, so maybe later I can cite myself on this, but the gist is that a lot of short mental health screening questions get false positives from perfectly healthy people. For example, I can’t tell you how many patients I’ve asked “Do you ever feel like anyone is spying on you?”, they say “Yes”, I ask “Who?” and they say “The NSA on my Internet activity”. Well, good work keeping up with the news. But a survey with a checkbox and no followup questions diagnoses that person as psychotic (see also: Lizardman’s Constant). This prison questionnaire was smart enough to exclude prison guards, who are certainly spying on all the respondents, but even beyond that I feel like the criminal lifestyle really does involve being spied on and plotted against a lot. At the very least it gives you lots of opportunities to legitimately worry about it.
(also, the diagnostic criteria for psychotic disorder are very clear that paranoia experienced while taking drugs doesn’t count. 75% of prisoners admit to using marijuana, marijuana can totally make you paranoid, and as far as I can tell the survey did not specify that the paranoia had to be while sober.)
(also also, Scientific American says that about 5-15% of perfectly ordinary people hear voices. Meanwhile, 4-6% of prisoners in the survey admitted to it.)
When the survey says that X% of prisoners have felt plotted-against or heard voices in the last year, does that mean X% of them are psychotic? That X% of them are “severely mentally ill”? That the old state mental hospitals need to be re-opened so X% of them can be locked up there for being too crazy for society? I don’t think it means any of those things.
But this is the stricter of the two criteria that the survey uses! The other one counts depressed people, bipolar people, and psychotic people. I don’t want to trivialize non-psychotic illnesses like depression. But remember: about 10% of the ordinary non-prison population is depressed/bipolar/psychotic. Also, going to prison is depressing as heck in and of itself. When they say that 15% of people in county jails (rounded up to 20%) are severely psychiatrically ill, they’re talking about pretty normal people, who might be in prison for something unrelated to their mental illness and might not even have become mentally ill at all if they hadn’t been incarcerated.
So I don’t think this survey shows the majority of the mentally ill prison population is in need of institutionalization. Yes, ten times more mentally ill people are in prison than in state mental hospitals, but consider the base rates! The prison population is huge. The population of people who need to be committed to mental hospitals 24-7 is tiny. Even if mentally ill people committed crimes at exactly the average population rate, there would still be far more mentally ill people in prison than in psychiatric hospitals, just by base rates! Especially if you use as broad a definition of “mentally ill” as these people!
So when Vox says that ten times more mentally ill people are in prison than in psychiatric hospitals, I will shoot right back at them that ten times more mentally ill people are in the Los Angeles metropolitan area than in state mental hospitals. You want more meaningless statistics? Ten times more mentally ill people are in the Southern Baptist Church than in state mental hospitals! Ten times more mentally ill people watched the last season of Game of Thrones than are in state mental hospitals! We can’t and shouldn’t aim to institutionalize all of them.
IV.
What about that graph? It’s very suggestive. You see a sudden drop in the number of people in state mental hospitals. Then you see a corresponding sudden rise in the number of people in prison. It looks like there’s some sort of Law Of Conservation Of Institutionalization. Coincidence?
Yes. Absolutely. It is 100% a coincidence. Studies show that the majority of people let out of institutions during the deinstitutionalization process were not violent and that the rate of violent crime committed by the mentally ill did not change with deinstitutionalization. Even if we take the “15% of inmates are severely mentally ill” factoid at face value, that would mean that the severely mentally ill could explain at most 15%-ish of the big jump in prison population in the 1980s. The big jump in prison population in the 1980s was caused by the drug war and by people Getting Tough On Crime. Stop dragging the mentally ill into this.
Lopez himself wrote a nice piece on how most mentally ill people are not violent, and another nice piece on how most people in prison are there for violent offenses. But put these together, and you get that most mentally ill people do not end up in prison. Most of the people who got out of the mental hospitals during deinstitutionalization are getting by. Some of them are homeless, and that’s bad. But if you want to solve homelessness among the mentally ill, build homeless shelters, not state-run long-term mental hospitals.
V.
In case you haven’t noticed, I really don’t like state-run long-term mental hospitals. There is a really amazingly great thing about prison, which is that you don’t go there unless you’re convicted of a crime. Mental hospitals do not have that advantage. The commitment process kind of sucks, and I am saying this as a person who makes commitment decisions myself. A lot of times it degenerates into a ritualized method of avoiding lawsuits without much concern for benevolence or patient autonomy. It helps me sleep at night to know that most commitments only last a couple of days or a week at most. Long-term state-run mental hospitals didn’t work that way. Remember that some of the perfectly sane people in the Rosenhan experiment were kept locked up for fifty days just for saying they heard a voice once but now they’re better.
I think long-term state-run mental hospitals are better than prison, but not by very much. The Rosenhan participants described it as:
…an overwhelming sense of dehumanization, severe invasion of privacy, and boredom while hospitalized. Their possessions were searched randomly, and they were sometimes observed while using the toilet. They reported that though the staff seemed to be well-meaning, they generally objectified and dehumanized the patients, often discussing patients at length in their presence as though they were not there, and avoiding direct interaction with patients except as strictly necessary to perform official duties. Some attendants were prone to verbal and physical abuse of patients when other staff were not present. A group of bored patients waiting outside the cafeteria for lunch early were said by a doctor to his students to be experiencing “oral-acquisitive” psychiatric symptoms. Contact with doctors averaged 6.8 minutes per day.
The idea of potentially saving a couple of people from prison by pre-emptively committing way more people to a mental hospital does not appeal to me at all, and I still think closing the institutions was the best thing Reagan ever did.
But prison and institutions aren’t the only two options! There’s a six month waiting period for psychiatrists in most parts of the country. The existing mental hospitals – which are different from and often nicer than the old state-run institutions – are constantly turning away people who want to be there because they don’t have enough beds for them. There are a bunch of patients who are having trouble affording their medications. There are special treatment options like day clinics, partial hospital programs, recreational therapy, occupational therapy, et cetera that do really great things but which most patients can’t afford. There are intensive health monitoring programs – think nurses who come to your house and make sure you take your medication on time – which are proven to improve outcomes but which never have enough staff for everybody who needs them. There are omnipresent underfunded community mental health systems. All of these things are doing great work right now. Indeed, the plan for closing the state-run long-term facilities was to gradually transition care to all of these other systems, and where that was supported it worked well, and insofar as it didn’t work well it was because it wasn’t supported.
If we support all that, will it keep all mentally ill people out of the prison system? No. First of all, no treatment is perfect and most are downright mediocre. Second of all, like I said, there are mentally ill people in prison because there are mentally ill people everywhere. There are disproportionately many mentally ill people in prison because the risk factors for mental illness are the same as the risk factors for crime, like poverty and drug abuse. Regardless of the level of care given, mentally ill people are likely to end up in prison at increased rates, unless you’re willing to either institutionalize all mentally ill people before they can commit any crimes, or excuse all crimes committed by mentally ill people.
But we shouldn’t be making our mental health decisions based on worries about criminality and prisons. Most people who are mentally ill will never end up on the wrong side of the law, and many (most?) mentally ill people who do end up in prison will do so for reasons not directly related to their illness. Make mental health decisions because it’s the right thing to do and there are people who really need help.
And if mentally ill people do end up in prison? There is a forensic health system dedicated to treating mentally ill prisoners. It’s not perfect, but with more funding and attention it could be better. There are forensic psychiatric hospitals that house mentally ill prisoners, and though again they are not perfect, they at least have that great advantage that you can’t be put in them unless you are found guilty of a crime.
So my argument is: fund and use the community mental health system more to help people in the community. Fund and use the forensic mental health system more to help people in prison. But stop acting like the two groups are fungible. And stop trying to institutionalize more people. That doesn’t help.
You had me until I saw the name Rosenhan.
Things went rapidly downhill after that.
I have written my representatives about this topic. There a people that end up in jails for mental illness who are NOT criminals. They may have one psychotic break and get picked up and put in the prison system. And as adults it is hard to even find out where your loved one is. It is sad and uncalled for and must be changed if we are a caring nation. It was a huge mistake to get rid of so many mental illness hospitals thinking that new medications would solve the mental health problems. That was hardly the case. I don’t believe there are even enough mental health workers to take care of all those who need the help and it is very expensive for many to get that help. It takes more than one visit to get proper therapy.
I don’t know for sure the statistics for mh patients in prison but tnis news report from California is very disturbing: https://www.youtube.com/watch?v=-HcjjUL7Q7g&ab_channel=FredMamoun
Did I really read “if the mentally ill want help?” Mentally ill people don’t have the capacity for logical decisions, ie listening to the voices in their heads and eating a part of their arm, or throwing their baby in the river. These people are going to ask for help?
Totally agree with the observation that the criminal justice system exploded when the mental health institutions imploded. Community mental health systems only handle the treated mentally ill in a less serious state of mind. Let’s reinvest in more humaine mental health institutions. My fear however, is that they will be staffed or understaffed much like our growing nursing homes for the aged.
There are degrees of mental health problems.
Someone can be suicidally depressed yet still have capacity to make treatment choices though their degree of capacity may vary from day to day.
There have been court cases where anorexic patients have been declared competent to choose to refuse treatment because they’ve demonstrated that they fully understand the consequences (death).
Saying that all mentally ill people don’t have capacity is like saying that all Orthopaedics patients can’t walk. Some can’t but some can. It depends.
It is somewhat misleading to say that most prisoners are in prison for violent crimes. A large number are there for drug crimes that have been “defined” as violent simply due to the amount or kind of drug involved, without regard to whether any actual violence was involved. These people populate the spectrum outlined by the author, but drug addiction is a primary reason for these offenses. In my part of the country, the attention to addiction has not reached the level I have seen described in most other nations with higher rated health care systems. In fact, the treatment is usually found in prison.
Also, there’s a shitload of people in prison and jails who wouldn’t be there if they hadn’t violated probation/parole with drug use. The statistics will, more or less properly from a legal perspective, say those people are imprisoned for the original offense that may not be drug related, but practically speaking that’s only a part of the story.
Do you have statistics to show this?
“Lopez himself wrote a nice piece on how most mentally ill people are not violent, and another nice piece on how most people in prison are there for violent offenses. But put these together, and you get that most mentally ill people do not end up in prison.”
These claims may all be true, but the fact that most mentally ill people are not violent and the fact that most people in prison are there for violent crimes, do not in themselves imply that most mentally ill people do not end up in prison, as you seem to be implying is the case.
Checklists are useless except as a reminder of what areas to explore. Horoscopes and fortune cookies evoke the same kinds of endorsement. As for the horrors of jail, I recall a particular patient who kept going through the revolving door when I was a young inpatient psychiatrist. I never saw him free of psychosis. He disappeared for about a year, returning to clinic with no active psychosis. He had been serving 11 and 29 in county jail. A month later, he was back on the ward, using drugs and psychotic. Was he mistreated by the judge who locked him up instead of sending him to the hospital?
Drug induced psychosis? The prison making sure he takes his meds? Or lack of medical insurance for meds outside of prison? Other?
Just wanted to let you know, this article changed my mind. I’ve spent some time around mental hospitals, was of the opinion that Vox espoused in the article, and this writing successfully challenged and deepened my perspective. Thank you.
I agree with much of what you say, but:
>The share of GDP devoted to mental health is the same as it was in 1971, although this looks worse if you compare it to rising costs in other areas of health care.
This is the problem I have. First, as you point out mental health as a share of total health care costs has gone down. Since the price of hours-with-a-provider has gone up across the board since the ’70s (relative to GDP too, I think) this indicates less care is being provided total.
Second, perhaps the same share of GDP is being spent on mental health care in total–but more of that share is rich people/rich people’s insurance spending money on the mental health of the people who are already best off. Meanwhile, it’s an obvious fact that since Reagan, less of the government’s money is being spent on mental health care for people who can’t afford it on their own.
There’s really no way to tell from anything you say what percentage of mentally ill people in jail or on the streets are there because they’re mentally ill. What you say is almost as speculative as what the Vox guy says. It’s entirely possible, for all you say here, that the present-day situation is worse for the mentally ill than in the days of state hospitals, and that it’s worse because the state hospitals were closed.
I’m posting from my phone since I’m at work, so I hope I may be excused for not being as eloquent as I’d hope to be otherwise.
While I don’t see anything to disagree with in your criticism of the Box piece, I did want to point out an important issue that you kind of skip past. You say in your last section that “there are forensic psychiatric hospitals,” but that’s not universally true. My state of Virginia does not have any for juveniles. This means that if you are arrested and/or convicted of a crime and are under 18, you get sent to the regular juvenile penal system, no matter your mental state. Of course, those facilities are not remotely equipped to deal with someone with, say, full-blown schizophrenia. No one in state government seems willing to fix this, since it involves spending money on people, and we’re not really about that. Even though a member of our legislature was stabbed by his mentally ill son, who was only at home because there were no beds available for emergency admissions.
So again, I don’t think this undercuts your overall argument, but I wanted to point out that there are not necessarily the treatment alternatives for those who have broken the law that you mention. As you say, mental health programs are criminally underfunded, and this regrettably leaves jail as the only option in some cases.
I also think you understate the legal process centered around involuntary commission. I don’t disagree regarding the fact that long-term hospitalization can become indefinite. But the initial process does involve more procedural safeguards than you suggest, including a hearing with a right to a lawyer (with one being appointed at the state’s expense if need-be). This is often more than is given to those languishing in jail because they can’t afford to make bail. Not exactly a laudable comparison, but nonetheless the process is not as draconian as you say.
It’s rather unfortunate that The Last Psychiatrist deleted “The Terrible, Awful Truth About SSDI”, because that would seem the perfect companion to this piece.
Is it the Wayback Machine, I wonder?
It is https://web.archive.org/web/20101129141646/http://thelastpsychiatrist.com/2010/11/the_terrible_awful_truth_about_1.html
I’d have to check again, but I remember there being a number of good TLP articles that are no longer on his site, but still show up in the Wayback Machine.
Looks like it’s reprinted here:
http://davidmarsden.tumblr.com/post/47216977797/the-terrible-awful-truth-about-ssdi
>There are forensic psychiatric hospitals that house mentally ill prisoners, and though again they are not perfect, they at least have that great advantage that you can’t be put in them unless you are found guilty of a crime.
Unless you’re being held there to evaluate your competency to stand trial, which is 30 days at a minimum.
Also, something like 90% of felonies never go to trial; they’re plea bargains. Let’s say your roommate gets caught with drugs and guns, and because you were in the apartment you also get charged with possession of both. Pleading guilty to drug possession might look good if it buys you safety from the gun charge.
..But yes, better community services, please.
Since this blog is keen on writing tips, I have two:
1. Commas and periods go INSIDE quote marks, not outside.
2. It goes without saying why “needless to say [something I’m going to say anyway]” is bad writing. See what I just did there?
re: #1, not necessarily. It’s a British thing, and many experts prefer them to go outside. (And IMO it does make sense: the period marks the end of a sentence, and should be at the end.)
See Steven Pinker’s wonderful “A Sense of Style”, for example. Or here is an interview in which Pinker defends, among other things, the outside comma/period.
I typically put them outside when they’re not part of the quote. It just makes more sense.
I also put them outside with “scare quotes” or “terms of art”, since I think it looks silly to put them inside, as if the comma were part of the quoted phrase.
Re: #1: That rule is dumb, and I decline to follow it. I’m glad to see other people also ignoring it.
(I like Pinker’s quip: “Messing up the order of delimiters in a way that doesn’t reflect the logical nesting of their content is just an affront to an orderly mind.”.)
(See what I just did there?)
Now I’m in an impossible bind: having been taught from a young age that commas and periods always go inside quotation marks, putting them outside looks disorderly and wrong. But logically it makes sense to put them outside when they’re not part of the quote.
When it’s something like “John said, ‘I’m going home,'” I put it inside of the quotes.
But when I’m putting quotes around a “term of art”, then I put it on the outside.
When writing plain English, I do the old-fashioned rules of usually putting the punctuation inside.
But too often I’m talking about computer syntax, and I can’t tell the user to make their username “George.” Because is that 6 or 7 characters?
It looks weird to shift back-and-forth, so if I have any quantity of computer code I shift to the other usage.
I like this. When the quote is a full sentence, then it deserves its own punctuation, which should not affect any of the normal punctuation in the sentence in which it is embedded.
Luckily for people like us, English doesn’t have a formal authority, so we can do what we like.
I noticed that Scott’s parentheticals did not start with capitals. Is he trying ot pass off “(” as the first letter of the sentence?
I thought “(” was a capital 9.
Re #2: the phrase exists for a reason or it wouldn’t be a phrase. It can be overused, or used badly, but it’s not bad writing on its own.
More specifically, it’s perfectly normal in popular writing to occasionally mention things the reader already knows. Wouldn’t it be nice to have a way of saying you’re doing that?
“needless to say” signals “I think most of my readers know this but for the few who don’t…”
Or, alternatively, “there are several valid conclusions that can be drawn from what I have just said. I don’t want to insult your intelligence by suggesting you haven’t gotten it already, but the one I want to use to further my argument is X.”.
I deliberately countersignal against the punction-inside-quotations rule, and so should all of you up until such time as it would endanger the effectiveness of my countersignalling strategy.
I’m a level 5 contrarian, I don’t have any opinions held by more than 6 people.
The Wikipedia discussion of this subject.
Reminder that Strunk and White’s classic “Elements of Style” includes Strunk’s wonderful rant against the phrase “the fact that…”
I have found some rare rhetorical-flow uses for “the fact that”, but for the most part I’ve agreed with its removals.
The one that’s blown my mind recently is that punctuation is meant to be placed after the parentheses.
Any mention of Elements of Style now reminds me of Geoff Pullman’s takedown.
Thanks for the link. I read Elements long after my grammar education was over, so while I found it fun to read for its distinct personality, I don’t think I actually picked up any grammar issues from it.
Why do you think so many writers say things like “needless to say”, if it’s bad writing?
I suspect that Scott used the term to serve two goals, to both smoothly lead the reader through the steps in his logic, and also to avoid insulting the reader’s intelligence. Scott has summarised the Vox argument and now is moving to his introduction. At this point, it is useful to repeat his position. But since his post heading and earlier bits implied his position, Scott suspects his modelled reader, being intelligent, will already know he disagrees. The ” needless to say” is a nod to that intelligence. Plus, a not-so intelligent reader can get a useful recap they might need.
There are probably other ways of achieving the same goal, with their own trade-offs. There is perhaps an even better potential way out there that might make the difference between a Scott and a Shakespeare. But, that doesn’t mean that Scott’s choice of wording is actually redundant.
Commas and periods go INSIDE quote marks, not outside.
“That’s not how I learned to do it”, she typed. 🙂
“I’M NOT A PART OF YOUR SYSTEM”!
I’d like to take this opportunity to ask what the deal is with “private prisons.” They seem to be a progressive bugaboo lately, as well as a talking point about why “some things just can’t be privatized,” yet I don’t actually know of any private prisons that actual criminals have been sent to, or, if they are prevalent, why they are supposed to be so evil. I’ve seen Facebook memes showing crowded bunk beds, but I’m not sure that that is any worse than all the shanking tv and movies tells me goes on in non-private prisons?
They’re fairly clustered in certain regions. You wouldn’t be surprised which ones, so if you don’t live in those areas you’d never hear about them even if you did have reason to hear about particular prisons (which obviously most people don’t).
Although certain private prisons have been called out as particularly subpar, I think the main thing most progressives worry about is giving a private company an incentive to increase or at least maintain the prison population, plus concerns about rehabilitation, all within the general context of progressives not assuming that the private sector is intrinsically more efficient. Speaking for myself, I don’t assume that the average private prison is notably lower in quality than the average state prison, but I still think it’s an awfully bad idea because of those incentives.
“giving a private company an incentive to increase the prison population”
What about the government’s incentive to increase the prison population?
Far far less explicit.
The state has mixed incentives. Their voters want lower taxes and that has to be balanced against other desires.
With the company the only thing the company shareholders want is more money. This can be achieved through careful lobbying or corrupting the justice system. The private prison system has been caught doing both on a number of occasions with judges being given kickbacks for long sentences.
True, but prison guard (public) unions have a strong incentive to lobby for minimum sentencing laws, etc.
It seems that all companies have an incentive to increase the perception of need for the product or service they are providing. Dentists have an incentive to increase tooth decay, Burger King has an incentive to make you hungry, and defense contractors have an incentive to increase war.
I’m not saying these incentives don’t really exist, but rather that they exist for everything, so I’m not sure one can point to them as the source of any problem, nor as a reason for having the government do x, unless you want the government to do everything.
One might argue that competition is good when it’s competition to produce good things, but bad when it’s competition to produce bad things. But we don’t actually consistently produce anything most people think is bad, I don’t think: prisons seem to be “bad,” but it’s actually the needing of prisons which is bad. One might say, “okay, then don’t give companies an incentive to create things the needing of which is bad.” But by that logic we should expect private doctors to create illness, private dentists to encourage tooth decay, and private security guards to cause crime, which really doesn’t seem to be a problem.
“But by that logic we should expect doctors to create illness, dentists to encourage tooth decay, etc. which really doesn’t seem to be a problem.”
It might be a problem if doctors and dentists had total 24/7 control over the lives of their patients, or if they had almost zero structural reasons to respond to the desires of their patients, or if they didn’t have longstanding professional norms enforced by both the courts and their professional organizations to treat their patients, or if the number of sick people could be simply and directly increased legislatively.
Original CC,
It seems the opposite. Unions want to maximize employment for their members, and thus are incentivized to overstate or make worse the problem for which their labor is the solution.
“It might be a problem if doctors and dentists had total 24/7 control over the lives of their patients”
I think the problem here is the mistaken perception that criminals are the “customers” of prisons. They are not. The rest of society is the “customer” receiving the service of having the prisoners kept away from them.
If there is a bad incentive, it’s to frighten the populace into thinking there is more need for incarceration than there really is (or to actually create a need for more incarceration by doing things that encourage criminality).
“If there is a bad incentive, it’s to frighten the populace into thinking there is more need for incarceration than there really is (or to actually create a need for more incarceration by doing things that encourage criminality).”
Yes, this is our concern–that private prisons will lobby for further criminalization to increase the prison population, and that they will neglect rehabilitation (which remains a proper role of the correctional system to many people even if it isn’t to you) primarily to save costs but with at least an incidental similar consequence.
@onyomi
I would argue that the smaller the number of actors the easier it is to coordinate an effective strategy to achieve their goals.
Burger King is going to be more powerful than a huge mass of unaffiliated small restaurants. Especially if lobbying helps lots of actors in the same industry but the costs are borne by just one.
Dentists have an incentive to increase tooth decay as a group and if there was one company running all the countries dental surgeries then it would be more likely they would act on that. 10,000 small dental firms individually have almost no incentive to increase tooth decay nationally. Any one dentist spending resources to increase tooth decay would benefit them all but only benefit themselves a little while carrying the costs. On the other hand individually they have a strong incentive to be perceived as advocating to reduce it.
Defense contractors actually do have a very straightforward incentive to increase war.
Incentives exist for everything but sometimes the conditions make it practical to act on those incentives.
There’s a relatively small number of actors in the private prison market. If there was a tiny private prison for every dental surgery in the country and they were all independent then I suspect that a lot of the perverse incentives wouldn’t manifest actual problems.
Eh, there aren’t that many prison guard unions either, and they have a strong incentive to increase incarceration too. And politicians always want to look tough on crime.
Heck, the whole reason there are private prisons in the first place is that we were incarcerating so many people that the regular state-run prisons were getting unaffordable. If there was a check on incarceration before, it wasn’t very strong.
Honestly the link between private prisons and increased incarceration seems pretty weak. If anything they might have an incentive to cut corners (thus being inhumane) to save costs.
I suspect private prisons are a progressive bugaboo simply because progressives tend to be against privatizing any government function, want to support public employee unions, and have a disgust reaction to people profiting from incarceration.
Prison guard unions have also been a progressive bugaboo if I remember correctly, just not recently. I swear I remember Arnold railing heavily against them at some point, but maybe calling him ‘progressive’ is stretching the word a bit.
I don’t think doctors and dentists on any individual basis have much of an incentive to increase demand for their services because it’s effectively already at max capacity as far as quantity demanded. Most of them have queues that never empty. The incentive they have is to increase capacity to pay, i.e. lobbying for greater Medicare payouts or whatever else it is that increases healthcare costs. Prison owners can much more easily build new wards than doctors can clone themselves or cut patient visit times even shorter than they already are. That sort of incentive would be more on the hospital end, but even hospitals can’t do much to increase the supply of doctors because it takes a long time to make one and most people can’t do it, though we definitely see them shifting duties to nurses and other formerly auxiliary staff that it’s easier to make more of. Staffing a prison is still much easier, though.
But yeah, prison guard unions and politicians wanting to be seen as tough on crime (and elected judges are probably about the worst on this) are just as bad as private prisons.
If anything they might have an incentive to cut corners (thus being inhumane) to save costs.
I think that this portion of your comment could serve to inform the remainder of it.
” Dentists have an incentive to increase tooth decay, Burger King has an incentive to make you hungry, and defense contractors have an incentive to increase war.
I’m not saying these incentives don’t really exist, but rather that they exist for everything,”
No, they exist for everything private. If make something public, then by default there is an incentive against it, in order to lower taxes.
That’s a remarkably simplistic way of looking at the incentives around public goods. Taxpayers have an incentive to minimize their taxes, but that couples only very weakly to any specific policy. And few people that’re getting paid out of those taxes have any such incentive — politicians sometimes might, but they have a tragedy-of-the-commons problem in that tax burden falls on the entire tax base while program benefits are more local. The latter often wins.
Outside of elected positions, everyone in government has self-serving incentives very similar to those that private actors have. An agency formed to fight, say, tooth decay may not precisely want to maximize it, but it certainly has an incentive to make it look like a serious problem, in order to secure continued funding and, ultimately, existence.
I think that this portion of your comment could serve to inform the remainder of it.
Did it not? because that’s why I included it. That there are plausible rational reasons to be against private prisons does not preclude the possibility (and frankly probability) that there are also common non-rational and tribal reasons to make it into a “bugaboo”. This is typical of most politics.
Anyway, the mistake is not noting that private prisons have some perverse incentives, it’s ignoring that public prisons have many of the same incentives (you don’t think public run prisons have pressure to cut budgets?). With the added disadvantage that it’s usually a lot harder to get redress from the government, and a lot harder to kill a dysfunctional government agency than to switch contractors.
And there is certainly a subset of people who are strongly opposed to private companies doing things that they think the government ought to do, even if (big if of course) the results are equivalent (hence “disgust reaction to profit”). Probably not a majority, but often its the least rational “tribal signaling” objections that put off the most heat (and least light).
No, they exist for everything private. If make something public, then by default there is an incentive against it, in order to lower taxes.
There is also by default an incentive for it, in order to increase the power and prestige of the civil servants who run it.
The former, tax-cutting incentive is so broad and shallow that in most cases just about every person subject to that incentive finds it insufficient to motivate action or even knowledge and so remains rationally ignorant of all the details of the subject.
The latter, scope-increasing incentive is narrowly focused on people who will find it profitable to devote most of their time to office politics focused on that goal, and these people are by definition veteran insiders in the political realm. They are surrounded by lesser civil servants who are sufficiently motivated to e.g. vote on the issue but not to carefully follow which politician voted for which statute with what consequences and will instead do what they are told by the union.
Considering this balance of incentives, is it likely that the prison system and its associated bureaucracy will grow or shrink?
The fact that private prisons aren’t more broken than. for instance, private medicine isn’t much of an argument unless you can show that private medicine isn’t more broken than public medicine. But there is evidence that it is, in the form of high US healthcare costs.
There is an argument for nationalising the more-is-bad things, and privatising the more-is-good things, because then the incentives go in the right direction in each case.
“No, they exist for everything private. If make something public, then by default there is an incentive against it, in order to lower taxes.”
I think you have it almost exactly backwards.
My relation to the government’s activity of taxing and spending is almost entirely involuntary (“almost” because my vote has a minuscule probability of changing outcomes and because I could emigrate). My relation to my dentist is entirely voluntary.
If the government does something that benefits some well organized interest group at my expense and that of almost everyone else, as governments routinely do, we have neither significant incentive nor ability to do anything about it. If my dentist does something that benefits dentists at my expense, such as advising me against brushing my teeth or putting in a crown that will soon come out, I can change to another dentist—and have an incentive to do so.
Obviously that isn’t a perfect system, because I might not realize that the dentist was acting against my interest, but it is a great deal closer than the public (i.e. governmental) alternative.
First, to clear the air–I don’t think private prisons are a relevant piece of the puzzle when it comes to explaining current incarceration rates, contra dumb liberal Facebook memes. There aren’t enough of them and they haven’t been around long enough.
Second, I disagree that the all same incentives are there with public prisons. The key, imo, is to look at the actual actors rather that trying to birds-eye-view the institutions holistically. So who are the players? First, you have the actual prison staff, up to and let’s say for the sake of argument including the warden. Public or private, all the same–they have fixed salaries/wages. They don’t receive any noticeable benefits for cost savings or reduced recidivism. Their incentive is to keep things orderly and work just hard enough to not get fired.
But who wardens the warden? In the public system, it’s going to be some high level bureaucrat in pretty much the same position. Maybe he has political ambitions and wants to be under budget to further them, but that’s a really big if. Most likely, he also just wants to avoid screwups and collect his paycheck. His boss, in turn, is a politician for whom the correctional system is only one portfolio amongst many, and who may want to save money, but is aware that no governor was re-elected because of his DOC budget. He, too, is far more motivated by avoiding the bad than seeking the good.
Contra a private system: there, the warden’s warden is much more likely to be someone with stock options, the potential for bonuses. His boss is certain to be such a person. Where everyone else is disciplined pretty exclusively by the stick, these folks also have the potential to eat some very delicious carrots.
This is, in fact, the entire appeal of the private sector–an increased ability to pass down motivations and desires from the top, rather than layers of bureaucrats whose main desire is a steady boat on calm waters. If you want a stable system that seeks, above all, to avoid screwups, you want the public sector. If you want something dynamic that will take risks in furtherance of the goal of efficiency/profit, you want the private sector. I can easily see why people would chose the latter for most things, but to me it’s clear that the former is best suited to a correctional system.
All that said, I will cop to a basic Blue-tribe disgust with getting rich off of putting people in cages. It’s not rational, but then, what is?
What sort of incentive are you thinking about?
[Edit: ninja’d by everyone; should have refreshed first. But my query about how the incentive to lobby for more punitive policies isn’t a extra source of unnecessary criminalisation, rather than an alternative one, still stands]
Could you go into more detail on that?
Do you mean ‘people will vote for get-tough policies, even when they are less effective than other ways of reducing crime, therefore politicians will respond to that incentive by enacting laws that result in more people in prison’? If so, that’s a problem, but it’s a problem regardless of whether the prison is run by the government or the private sector; whereas with private sector prisons, the ‘we get more money for imprisoning more people for longer, regardless of whether that actually enhances public safety / reduces recidivism relative to other ways of spending that money etc’ incentive would appear to be an additional problem, not an alternative one.
What have I missed?
I think a lot of the concern traces to the capacity of a private prison for converting tax dollars back into political contributions, which can have a much more directly distorting effect on the motives of individual politicians.
Unions are the biggest political donors in the United States.
I take it that “unions are the biggest political donors in the United States” isn’t intended as a non sequitur. So presumably the implication we’re to read is something like: unions already convert tax dollars back into political contributions, so there is already as distorting an effect on the motives of individual politicians. And possibly: if anything, the effect of private prisons would yield a balance of distortions.
If all anyone is worried about is the degree of distortion, and not the type, I think that’s probably more right than wrong. Both types of pressure probably serve to increase taxes. But I think there are important, justifiable differences. In particular, what unions typically lobby for affects supply and demand only indirectly, except in special circumstances (when the “market” is shrinking rapidly, for example). Teachers unions fight for fewer students per classroom, and thus more teachers, but typically don’t lobby much for more students (“Make private schools illegal!”?).*
But when a private prison has 20 empty cells, they might really need a favor *right now*. And in a state where judges are elected (making them politicians) that can get ugly in different ways than union contributions make them ugly. So the concentrating effects of wealth (and worries about losing wealth) can wind up distorting the system in different ways.
* In your face, Demosthenes!
“Teachers unions fight for fewer students per classroom, and thus more teachers, but typically don’t lobby much for more students (“Make private schools illegal!”?).*”
The teachers’ unions have been the main opponents of voucher initiatives.
That’s like the main thing teachers’ unions lobby for.
A likely immediate effect of adding school vouchers to a district is that a significant number of students would shift to private schools over a short period of time. So that’s one of the factors I was trying to capture with the note about rapidly shrinking markets. The pressure for the auto bailout in the recent financial crisis was a similar thing.
It’s something that offends many people on a values level. The object-level differences between private and public prisons have generally been shown to be fairly minimal.
Private prisons are a small fraction of our total prisons – 6% of state prisoners and 16% of federal prisoners. They spend less on “tough on crime” lobbying than either prison guard unions (who work at both public and private prisons) and police unions. Most of their lobbying money is spent on… getting more contracts awarded for private prisons instead of public ones.
The actual deal with them is that they may be worse than public prisons, and they may be a horrible idea based on moral principles, but they definitely aren’t the cause of our massive incarceration problems. But, there are so many other busted parts of that system (some of whom enjoy popular cultural support) that they’re an easy scape-goat.
It seems like it would be easy to fix the incentives if we wanted to. Private prison gets a flat rate to take care of as many prisoners as the state wants to send them, up to 120% of the current number.
What private prisons do have is an incentive to cut costs. Like, they get rid of the staff psychologist, and send you to solitary when you start raving that the fluorescent lights are talking to you. Or they cut funding for antidepressant meds, and replace your orange clothes with paper coveralls too weak to act as a noose.
I have a problem with it because it sets up an incentive for the private prison industry to, for instance, literally write laws that funnel more people into the prison system.
This Pennysylvania example is one of the most notorious examples, which I believe was also used by TV show Leverage for their private prisons episode.
One case where the private prison was empirically worse than state-run prison.
I was about to link the PA example myself – so I’ll settle for quoting the article for those who don’t feel like following the link:
Two judges, President Judge Mark Ciavarella and Senior Judge Michael Conahan, were convicted of accepting money from Robert Mericle, builder of two private, for-profit youth centers for the detention of juveniles, in return for contracting with the facilities and imposing harsh adjudications on juveniles brought before their courts to increase the number of residents in the centers.
For example, Ciavarella adjudicated children to extended stays in youth centers for offenses as minimal as mocking a principal on Myspace, trespassing in a vacant building, or shoplifting DVDs from Wal-mart.
It takes two to tango. Why is the private prison more blameworthy than the corrupt public officials who accepted the bribe? Strangely, their status as public “servants” did not turn them into angels, yet the main argument against private prisons relies on “public servants” being inherently more moral.
Re: private prisons
In the USA there has been at least one cash for sentencing conviction; a judge in Pennsylvania sentenced juvenile offenders to maximum sentences and they were then sent to various private prisons, who in turn paid the judge for the maximum sentencing.
In the UK, apparently they’ve been in operation since the 1990s. They run under PFI (Private Finance Initiative); the main objection to such Public-Private Partnerships seems to be that the private companies ‘bake in’ compensation clauses in the contracts, such that even if they don’t make the forecast profits/cost cuts, they will still receive the same level of government funding.
It’s hard to know if they’re better or worse; one report said they were better than public service prisons (and that was then criticised for selective use of data), another (issued by the Ministry of Justice) had statistics saying they were worse.
One of the companies (G4S, formed from the merger of Group 4 and Securicor) has since lost its contract to run the first private prison and has not won any other new ones. G4S was also in trouble over its (alleged, pretty shoddy if true) mismanagement of security for the 2012 Olympics in London, for which it won the contract then had to rely on the Army being drafted in to make up for the shortfall when it didn’t recruit enough staff.
Another large company is the French company Sodexo, which I am most familiar with as providing catering services to large organisations. Truly diversification at work, from providing canteen meals to running jails!
The third major group involved in providing private prisons in Britain is Serco, a British outsourcing company which was embroiled in a series of overcharging scandals for the provision of services to various government departments after those services had been privatised, the nastiest of which was probably the allegations of sexual abuse of women detainees at an immigration detention centre it runs.
The major objection to private prisons comes down to the fact that it is in their financial interest to have the maximum number of occupants for the maximum sentence length. You can argue that this takes criminals out of circulation, or you can argue that this pushes for giving people inappropriately long sentences for what are minor offences and works against rehabilitation.
It’s also in the financial interest of the guards’ union for a public one.
Excellent post attacking this oft-repeated claim. A few points:
Which should speak to the definitions of “mentally ill.” As per my recent column:
Features and Bugs
…that fraction is way too high.
Absolutely not. See the work of Amir Sariaslan, particularly his work into neighborhood and poverty effects on mental illness and crime. ALL of that factors you list are FULLY genetically confounded. That is, they are not causal in any way.
Those notwithstanding, you do a good service here, especially by pointing out that most people in prison are there for good reasons. Of course that’s a separate matter from the facts that prisons suck and could use improvement.
I agree that the old mental health facilities are a bit of a nightmare, and community rehabilitation is infinitely better, but this solution still seems a bit unjust. In the US prison is a punishment, and some of the mentally ill criminals can’t be held responsible for their actions. As such, doesn’t it involve punishing the innocent?
For dealing with people who have committed imprisonable crimes as a direct result of mental illness, wouldn’t it be preferable to have completely separate prisons with the same sentence duration, but focussing on positive mental health outcomes rather than punishment?
First of all, I do think that most mentally ill people in prison are there for reasons other than their mental illness – eg the pot dealer with depression. There’s a more philosophical question of whether his depression put him on a life course that led him to selling pot, but now you’re dealing with deep matters of justice and free will, where I think the distinction between mental illness and everything else becomes a little blurry.
There is already a forensic mental health system that deals with, for example, people found not guilty by reason of insanity. I think there are ways to transfer obviously mentally ill people from the normal prison into the forensic mental health system, though I don’t know much about them. I think these serve your role of “completely separate prisons with the same sentence duration, but focusing on positive mental health outcomes rather than punishment”.
Every state is different. There are various options, depending on level of mental illness:
1. Roger has schizophrenia, and likes cocaine. Stan has cocaine. Roger stabs him to death, and takes the cocaine. He goes to prison, because this is illegal (not just the possession of cocaine part; for that you can get a drug program.) The schizophrenia is not a defense; Roger formed the intent to (at least) rob and stab, and that’s murder. In most prison systems, Roger will have some mental health program access, designed primarily to keep him from stabbing other inmates. Participation is non-mandatory, but may generate privileges or earlier possible parole.
2. Pinky has a severe psychotic disorder. She believes that Fonzie is a murderous landshark who must be stopped, and runs him over with her motorcycle. Fonzie dies.
Because she lacks appreciation for her actions, and under her delusional beliefs, she would be innocent of murder, she is found not guilty by reason of insanity. Because of this, she will be housed until she is no longer a danger to the community. Maybe that’s a year from now. Maybe it’s never. And if Fonzie didn’t die… maybe it’s still never. Not guilty by reason of insanity can lead to life sentences for non-life crimes. It can also lead to earlier releases (usually supervised) for very serious crimes.
3. There are special civil commitment laws in many states for mentally disordered offenders and violent sex offenders. You can go to prison, and then get recommitted civilly. This usually has a high standard to require commitment with review periods to ensure the person is still a serious danger.
That’s a quick primer, and doesn’t cover a bunch of other things that happen. It’s also probably different in your state or country. Also, I am more expert than the next guy on this, but maybe not as expert as I ought to be, so could be wrong.
Actually, Pinky would not be found “not guilty”. She knowingly committed assault with a deadly weapon. Her honest belief that the person was not a human being doesn’t change that fact.
If she had been genuinely unaware of her actions–like, she was in a fugue state, or under the influence of amnesiac drugs like Rohypnol or Ambien–then her mental state might be a defense.
Yes, actually, not believing that someone is human is enough to get you off on murder. Or any other crimes that can only be committed against a human.
There was a 19th-century case where a man, his in-laws, and a few others (I believe) were charged with manslaughter instead of murder because the prosecution did not think they could prove beyond a reasonable doubt that they thought the person they killed really was a human being rather than the substitute the — ehem — Fair Folk had put in her place. There was just too much evidence that they were trying to rescue the real woman from the Fair Folk.
Andre Thomas butchered his wife and daughter and I think some in-law (been a while since I read about the case) whilst floridly delusional. Later, in prison, he ate his own eyes-two incidents one separate from the other. Found sane enough to be responsible.
Pinky’s outcome is by no means guaranteed
It’s one thing to be floridly delusional and yet another to have the specific delusion that would mean you would fail of mens rea. If you kidnap a baby under the influence of a delusion, you might be acquitted if you thought the baby was yours, but not if you thought the baby’s mother has stolen your inheritance and you wanted to use the baby as leverage to get it back.
At least in Massachusetts, the forensic hospital is really bad, probably worse than either a normal state hospital or a normal prison. It’s run by the Bureau of Prisons rather than the Department of Mental Health, which gives you an idea.
The courts are set up to avoid the not guilty by reason of insanity plea at all costs. It’s presented to juries as being similar to a not guilty plea (even the wording, it used to be ‘guilty but insane’) and prosecutors will go shopping for expert witnesses who will agree with them when the state doctors make an insanity determination.
I’m not familiar with the subject matter, but I just wanted to say that I really appreciate your concluding statements at the end – its easy to criticize a bad solution, especially in the arena of policy, and much harder to provide a good solution.
Scott, I usually agree with you and enjoy reading your stuff but I have a few nits to pick on this one. Not even sure where to start…
I read the Vox article and I simply didn’t get the same things from it that you did. Nowhere were they suggesting that the mentally ill are more likely to be criminally violent, nor were they suggesting we need to bring back the institutions. What I got from that story was that, *because* there are fewer alternative forms of support, police and the justice system are often the first responders when a problem occurs and family members of a mentally ill person don’t have any other resources to turn to. I’m sure you are aware that tragic shootings have occurred because police were called in to manage what should have been a non-violent encounter, but they were not well equipped to deal with the mentally ill person and somehow things escalated. So the Vox article argues in part that police and correctional officers should have better training to deal with these things.
Also you say: “There’s a six month waiting period for psychiatrists in most parts of the country. The existing mental hospitals – which are different from and often nicer than the old state-run institutions – are constantly turning away people who want to be there because they don’t have enough beds for them. There are a bunch of patients who are having trouble affording their medications. There are special treatment options like day clinics, partial hospital programs, recreational therapy, occupational therapy, et cetera that do really great things but which most patients can’t afford. There are intensive health monitoring programs – think nurses who come to your house and make sure you take your medication on time – which are proven to improve outcomes but which never have enough staff for everybody who needs them. There are omnipresent underfunded community mental health systems. All of these things are doing great work right now. Indeed, the plan for closing the state-run long-term facilities was to gradually transition care to all of these other systems, and where that was supported it worked well, and insofar as it didn’t work well it was because it wasn’t supported.”
This, this right there is what I see as the biggest problem. You’re right that funding was supposed to transfer from the institutions to a more community-based approach to care. But for the most part it didn’t. So you have people who need custodial care who can’t get it. You have family members who are not equipped to deal with a person’s special needs and they are left without many reasonable options. This huge gap in care is what has contributed to more mentally ill on the street, more mentally ill in prison, more mentally ill who are absolutely not getting adequate care and have no place to go.
I think you’re reading a different Vox article than I am. The one I linked to doesn’t mention first responders or police training at all.
Anecdote related to the ineffective survey: I was difficult to handle in grade school, and the school suggested a psychological screening. At the end of the process, I had an autism diagnosis, but early on, I was sent to the school counselor. Among other things, she asked “Do you ever see things that aren’t there?”
I was an imaginative kid, and I could definitely “see” things that weren’t there, if I wanted. So I answered “Yes!”
Cue much panic and handwringing from my parents, teachers, and therapists before the whole thing got resolved.
Hmmm….they seemed to see a mental illness there when there wasn’t one.
Heh. One time after acting out due to frustration with the other monkeys–er, fellow students–my teacher asked me if there was anything wrong with me. I said “well, I’m on drugs”. (My parents had given me an aspirin the previous night.)
I’m sorry I don’t have a citation handy for this but I recently attended a neurogenetics symposium where the keynote speaker was speaking about some of the results of some large population genetics studies.
There were some interesting correlations with professions.
There are genetic variants which are known to be linked to psychosis. They don’t make it certain that you’ll ever suffer from psychosis but they can make it more likely. When looking at the population they found that if you looked at people who had psychosis risk genes but didn’t suffer from psychosis they were significantly more likely to work in creative professions: artists, writers, painters, designers etc.
Speaking as someone who is not formally affiliated with psychiatry in any way… I have no problem with describing the person with auditory hallucinations as “severely mentally ill”. As I see it, although the consequences of her mental illness are not (yet?) significant, the difference between that person and a normally-functioning person is very large, and that by itself justifies the emphatic word “severely”. Similarly, I’d be happy describing someone who’d lost both his legs as “severely handicapped” regardless of whether he felt the absence of legs was an impediment to his lifestyle.
I’ve occasionally (maybe a handful of times a year?) thought I heard someone saying my name when nobody was, in fact, saying my name. For example, when I was a teenager and living with my parents, very occasionally when sitting at a computer doing computer-things I would think I heard my mother calling for me from the other end of the house, go out to see what she wanted, and she wouldn’t have called for me.
I was under the impression that that was a fairly common experience and also not indicative of significant mental health concern, and thought that kind of thing was what Scott was getting at. Maybe I’m wrong?
I tend to agree that that is a common experience and not indicative of significant mental health concern. I didn’t think that’s what Scott was referring to.
I think your reaction to learning that your mother hadn’t in fact called for you was probably something like “oh, I must have made a mistake; I heard something different while I wasn’t paying attention, or there was no such call at all and I merely imagined it” rather than “well, I definitely heard her call; supernatural forces must be at work”. I think hallucinations, if you ask the experiencer about them, provoke the response of “no, the stimulus is, according to my senses as they normally function, really there” rather than “oh, my senses momentarily misfired”.
But I’d be happy to be corrected.
I’ve had aural hallucinations a few times — in the sense of hearing human voices speaking about me, phenomenologically indistinguishable from what I experience when people are actually talking about me, as far as I can tell — and my reaction was basically, hmm, it’s extremely unlikely my parents and friends have gathered together in my neighbour’s flat to badmouth me at the wee hours, it appears I’m hallucinating. These episodes were brought on by stress, sleep deprivation, a rather sudden onset of more severe depression than usual, that sort of thing, and the hallucinations faded away once I got a couple good nights of sleep. I’m pretty sure that if I hadn’t been aware of the phenomenon of “hallucinations in the sane”, I might well have panicked, which in turn could have, for all I know, triggered an actual psychotic episode. As it was, the experience was actually rather interesting — if also somewhat irritating — and to whatever extent I could be said to have been “severely mentally ill” at the time, it has pretty much nothing to do with hearing voices.
When you say “…what Scott is referring to” – I’m referring to a survey that asked prisoners if they ever heard voices.
It sounds like if James had been a prisoner, he would have ticked “yes” to that checkbox and so gotten classified as “severely mentally ill”.
So it’s not really about what I’m referring to, so much as what the survey-taking prisoners thought was being referred to. I’m willing to guess a few of them interpreted the question the same way as James.
Michael, I think you’re conflating hallucinations with delusions.
People do hear voices calling them. I don’t know if that qualifies as “severely mentally ill”.
I often thought I heard my mother or a family member calling my name as a child and teenager, to the point where I’d come into the house/go into the room where they were and ask why they wanted me, to be told “No, I didn’t call you.”
Am I severely mentally ill? I really can’t make a decision on that one at this stage 🙂
Getting Samuel-and-Eli deja vu…
Are amputees who experience phantom limbs “hallucinating”?
Scott’s quest against Vox is starting to feel a bit Quixotic.
Re: poorly performed psychological surveys:
I’m strongly reminded of Richard Feynman’s story, recounted in “Surely You’re Joking, Mr. Feynman,” of how he was originally exempted from the WW2 draft not out of scientific need but for failing the psych exam (http://psychwatch.blogspot.com/2007/09/richard-feynman-gets-psychiatric-exam.html):
““Do you think people talk about you?” he asks, in a low, serious tone.
I light up and say, “Sure! When I go home, my mother often tells me how she was telling her friends about me.” He isn’t listening to the explanation; instead, he’s writing something down on my paper.
Then again, in a low, serious tone, he says, “Do you think people stare at you?”
I’m all ready to say no, when he says, “For instance, do you think any of the boys waiting on the benches are staring at you now?”
While I had been waiting to talk to the psychiatrist, I had noticed there were about twelve guys on the benches waiting for the three psychiatrists, and they’ve got nothing else to look at, so I divide twelve by three–that makes four each–but I’m conservative, so I say, “Yeah, maybe two of them are looking at us.”
He says, “Well just turn around and look”–and he’s not even bothering to look himself!
So I turn around, and sure enough, two guys are looking. So I point to them and I say, “Yeah–there’s that guy, and that guy over there looking at us.” Of course, when I’m turned around and pointing like that, other guys start to look at us, so I say, “Now him, and those two over there‑and now the whole bunch.” He still doesn’t look up to check. He’s busy writing more things on my paper.”
Damn you, you got this one in before I did.
This is exactly the way I’d have answered psych surveys if I hadn’t already read Feynman and other examples of poor superficial evaluations. Almost invariably I asked myself what any psych test or evaluation really meant by any given question before giving an answer.
It makes me wonder what the value is in some tests like the MMPI, where it’s fairly obvious what the question might mean to a psychologists, and that they’re trying to trip you up with some extreme absolutes against innocently moderate questions. At least, it seemed extremely obvious to me at the time–I might not have been the standard from which they were calibrated. I never tried to expressly manipulate the results, mind you, but what they ‘really’ intended by each question was always on my mind.
A lot of things on the MMPI are there to trip you up. They have questions like “I sometimes feel sad” just so that if you say “no”, they know you’re answering the questions in a non-literal way and can adjust for it elsewhere.
Insanity is carrying more about honest answers to arbitrary questions than appearing insane to psychiatrists.
Keep in mind, this was when he was called up to possibly serve in the army.
I’m pretty sure it’s illegal to lie to try to avoid it but answering utterly honestly rather than giving the “right” answers is perfectly legal.
From the rest of the anecdote I didn’t post, it also makes clear that Feynman was (1) really skeptical of psychiatrists, for good reason, and (2) inclined to have fun at their expense. Because, well, it was Feynman. This was the same guy who, at the same age, was giving everyone at Los Alamos heart attacks by cracking open their (poorly made) safes for fun. He was almost certainly giving honest rather than “right” answers to screw with the incompetent army psychs.
Also, it ends with him realizing that he may have gone too far if that psych evaluation affected him at Los Alamos, and wrote back a letter explaining that he believed the psychiatrist was wrong, but was crazy enough to not try to take advantage of it to avoid the draft.
If everyone thought like that there would be a hell of a lot of dishonesty in the world.
Oh wait there is, so people with higher principles are actually considered insane, on a low level.
If there wasn’t people like Feynman in this respect, people like that psychiatrist would ruin everything, but people like that are considered crazy, or failing that, often weird or difficult, for defending a standard we all rely on.
We are so lucky that the appeal of honesty outweighs these considerations in some people.
Being pedantically honest during a psych evaluation is not being more principled than considering what the question is really asking and answering that.
Doc: “Do you ever think people are spying on you?”
Patient thinks: Hmm, maybe this is a good time to make a political point about the NSA… or maybe I can tell that he is trying to discern if I am suffering from some sort of paranoia, and just say nah.
If you can infer the motive for asking a question like, ‘Do you ever think people are spying on you?’, couldn’t a schizophrenic do the same and give the answer that reflects the impression that they want to make rather than their actual thoughts?
Is that rhetorical?
Schizophrenics* who don’t want treatment will do that already. But my impression is that people with strong cases of, say, paranoia will try to convince the doctor that there really are the shadowy conspiracies out to get them. Schizophrenics will likely either want treatment to stop the voices that aren’t real, and answer honestly, or not believe that they hear voices that aren’t “real” and say no, or, possibly, give a self justifying answer about that time everybody else couldn’t hear it but it was real, etc.
Or maybe one is trying to get out of military service by passing as a borderline case by being pedantic. Or trying to get a laugh by pointing out to the administrator that you are smarter than the people who made the test. Not sure those are examples of higher principles.
Feynman’s story was funny, sure, but as a strategy it’s not recommended anymore than this: https://xkcd.com/651/
*May not be clinically accurate descriptions of schizophrenia, but I think the example still stands.
Randy M, I agree. I was just pointing out that that if the person answering the question is competent at inferring the motives of the examiner, the question detects the impression that the person answering the question wants to give instead of detecting whether or not the subject is delusional. Perhaps this is obvious.
That’s why those kind of questionnaires have always seemed useless to me. If you assume that people are answering them in a literal and straightforward way then you get a ton of false positives. But if you assume that people are just inferring whatever answer they’re “supposed” to give and giving that, then the information you’re getting isn’t remotely accurate.
I tend to be skeptical of questionnaires in general for that reason.
First off, of course someone like Feynman could choose to lie, but he’s disinclined to because he’s keeping track of what’s being said, and responding as if we should speak English to each other, rather than go-along-to-get-along -ese. That’s the kind of person he is. Without people who see the importance of truth, or are otherwise against the degradation of “consensus reality”, there’s no force against self indulgence, self interest, narrow mindedness, or any of a million things constantly chipping away at the sanity of, and constricting, “the consensus”.
-It’s not a case of being pedantically honest. It’s a case of being dedicated to the principle of honesty. If that causes you to fail a psych test, the problem is with the psych test, not with a person choosing to simplify their lives by always being literally and directly honest, or choosing not to pander to bullshit of the highest order.
You can consider this a quixotic and ridiculous position on the benefits of literal communication if you’re particulary short sighted, but what it absolutely fucking isn’t, is a mental illness.
Personally, I’m willing to lie if it’s convenient, and I’m not inclined to contradict people when they’re wrong, unless it’s necessarry. But without people who are willing to maintain the truth for it’s own sake, it’s a slow downward slide, because the beneficial effects of a less deluded society are long term and hard to track, aka “nebulous” or “imaginary”, in the mouth of any half assed demagogue, asshole, or moron, while there are a million selfish and stupid reasons to lie or delude yourself right now.
People with attitudes leaning in that direction are a necessary counterbalance against people like that psychologist. If people are weak, self indulgent and selfish, there’s a natural slide away from truth. Enough people are those things that we need people who are willing to shunt things right back to truth around. They are important. If they’re happy to do so, and if they decide to make doing so their default mode of existence, rather than something they calculatedly do, or shift gears into, when necessary, that’s even better.
Randy M would it be unfair of me to gather you have something against either honesty, or literal minded people?
(just read your next reply)
Of course, Feynman is assuming the psychiatrist isn’t just diagnosing him as a smart troublemaker, and thus a poor fit for the Army even in wartime.
At the end of the examination there was a guy who looked over your evaluation to decide whether you were in or out. Feynmann saw him checking a man’s spine, and observed at the time that this guy would clear it up.
The guy took one glance, saw psychological issues, and rejected.
Of course, Feynman is assuming the psychiatrist isn’t just diagnosing him as a smart troublemaker, and thus a poor fit for the Army even in wartime.
Or even deciding “This guy would be wasted in the army, it’s better if he’s working on necessary civilian projects” and writing up a psych rejection because he’s otherwise fit for service.
OK, I’m a bit puzzled by one of the comments on the Lizardman’s Constant post.
… the conclusion being that most of the second group were lying. Doesn’t it seem more likely that most of the first group were picking a word at random because that was the only realistic thing they could do? (The fact that the outcome wasn’t 50/50 isn’t surprising, seeing as humans are, I’ve heard, really bad at making random choices – I think this might be called the Swordfish Effect, or something like that?)
If the order of answers wasn’t randomized its possible people have a tendency to pick either the first or last option of a stupid question.
“I am incapable of expressing arbitrary preferences for words” is also much funnier than just picking one of two preference options, even when the options given do have some actual significance to them. A simple “no preference” would probably have been less popular. I’d bet money it’s a known thing among professional survey writers that including funny answers alongside bland ones on a multiple-choice question is a recipe for inaccurate results.
I imagine very few people do have a preference for one word over another (but then again, there are words I find euphonious, beautiful, well-structured; it’s just that “carrot” and “apple” don’t appeal to me with ‘one is clearly better than the other’).
The first question probably got answered along the lines of “Well, if I have to pick one over the other”, while the second test allowed people to think “Oh, I don’t have to answer this!”
We’re so conditioned by test-taking and “leave no question unanswered/fill in ALL the blanks” that, if it’s not specifically pointed out “you can say ‘I have no preference’ and that’s valid”, people are more likely to just pick one of the pair. Whether that’s at random, or they prefer the sound of one over another, is a different matter.
I don’t have a good model of mentally healthy murderers, rapists, and thieves. Wouldn’t murdering, raping, and a habitual theft indicate an empathy defect?
“In a way, each of us has an El Guapo to face. For some, shyness might be their El Guapo. For others, a lack of education might be their El Guapo. For us, El Guapo is a big, dangerous man who wants to kill us. But as sure as my name is Lucky Day, the people of Santa Poco can conquer their own personal El Guapo, who also happens to be _the actual_ El Guapo!”
Hmm… I’m not sure I understand your comment. Are you implying that my definition of mental illness is too broad? Maybe it is. Could you give me an example of a mentally healthy murderer? Do mentally healthy murderers make up a large fraction of convicted murderers?
Isn’t the criminal justice system just a hangover from a time when we used a different model of volition?
Who is we?
>Who is we?
People in general.
And you think people in generally no longer believe anyone responsible for their actions in a meaningful way? Or what?
‘And you think people in generally no longer believe anyone responsible for their actions in a meaningful way? Or what?’
No. Why would I think that?
Starting over:
What was our old model of volition?
What is our new model of volition?
Thanks.
An example of an old model would be the idea that a homunculus guides our behaviour.
Newer models can be found in introductory neuroscience textbooks.
I don’t mean to sound evasive. What I meant was that the criminal justice system dates back to a time when we didn’t use as much intellectual rigour to come up with methods of modifying human behaviour.
@Ted – “What I meant was that the criminal justice system dates back to a time when we didn’t use as much intellectual rigour to come up with methods of modifying human behaviour.”
So what specifically are the new, rigorous methods for modifying human behavior?
So what specifically are the new, rigorous methods for modifying human behavior?
Operant conditioning, psychopharmacology. rTMS, behavioural genetics, DBS, experimental ablation, microiontophoresis, et alia.
Humans are naturally really really good at suspending empathy for members of the outgroup.
Humans vary in how naturally good they are at this.
Of course, if you arbitrarily define something to be mental ilness it will be an illness. Maybe all people who are not nice are insane too, suffering from niceness deficit?
Not nice? I thought we were talking about murderers and rapists.
If an ‘organic’ cause is found, doesn’t the disorder shift from being a mental illness to a neurological or physiological disorder? I don’t support a practice that’s based on dualism, but it shows that the diagnostic criteria for mental illnesses are based on value judgments.
http://lesswrong.com/lw/2as/diseased_thinking_dissolving_questions_about/
https://youtu.be/fvg57FmCQ3w
Why would a lack of empathy be unhealthy?
I can easily postulate a hundred scenarios for a mentally healthy person to commit murder. Theft is even easier. Eldridge Cleaver raped a lot of women because he thought it was politically “insurrectionary”. While his politics were astoundingly atrocious, I don’t think its a sign of mental illness.
There is a brand of simple, pathetic, pacifistic ideology which cannot concieve that any sane person knowingly and deliberately hurts another. The adherents of this ideology have never been to Earth.
‘Why would a lack of empathy be unhealthy?’
If a lack of empathy leads other people to retaliate or have you arrested, it hardly seems like an optimal characteristic.
‘There is a brand of simple, pathetic, pacifistic ideology which cannot concieve that any sane person knowingly and deliberately hurts another.’
What does that have to do with mental disorders? Are you implying that psychopaths don’t know what they’re doing?
People tend to bristle at the idea of doctors being arbiters of morality, but I don’t. At least the rationale that medical doctors use ostensibly attempts to be empirical. That’s more than I can say for the heuristics that priests, lawmakers, and judges use.
“At least the rationale that medical doctors use ostensibly attempts to be empirical.”
Their rationale pretends to be empirical, and often successfully appears to be empirical. That makes it more dangerous, and, when the deception is deployed deliberately, more detestable — not less.
Eh… It has its flaws, but it’s still better than the rationale that priests, lawmakers, judges, and mobs use.
it’s still better than the rationale that priests, lawmakers, judges, and mobs use.
On what grounds?
On what grounds?
On the grounds that it’s (ideally) informed by scientific research and pragmatism. I trust the judgment of psychiatrists more than I trust police, lawyers, and judges. I would expect someone who studied human behaviour to understand human behaviour better than someone who didn’t.
Criminology and law are active research fields, and often go to some lengths to appear objective. Not always, and they don’t always succeed when they do, but the same could be said for psychiatry. And they definitely involve studying human behavior.
Priests don’t have those excuses, but depending on the religion they’d have had a few hundred to a few thousand years to work out the bugs, vs. fifty or so.
Criminology and law are active research fields, and often go to some lengths to appear objective.
Can you point to any groundbreaking experiments in criminology and law? Has the field of criminology yielded any technological advances?
Can you do the same for, say, cultural anthropology?
Can you do the same for, say, cultural anthropology?
No, and I trust psychiatrists and research psychologists over cultural anthropologists as well.
Could say the same for psychiatry, actually — it’s quite a different beast than research psychology, and does very little in the way of experimentation.
But the broader point is that a field’s methodology isn’t tightly tied to its rigor. You can’t create a supernova in the lab, but astronomers have found rigorous ways to study them anyway.
Not that I’d put any of those other fields on par with astronomy; I just don’t see a reason to privilege psychology and psychiatry above them, or to grant their practitioners any special trust.
Could say the same for psychiatry, actually
I disagree. There are specialised psychiatry journals that publish research on psychotropics and other forms of medical intervention.
Criminology, law, and cultural anthropology have not advanced in the way that medical science has.
We’re talking about psychology and psychiatry here, not medical science in general. Now, pharmacology’s advanced, certainly — though it seems to have stalled out a bit since the Seventies. And we’ve fleshed out our understanding of the underlying biochemistry. But have we gotten much better at using the same pharmacological resources? Do we have a better understanding of human behavior at the scales that psychology’s concerned with? And not just somewhat better, but standing out before any of the other human-behavior fields?
A couple years ago I might have been willing to say “yes”, but the ongoing reproducibility crisis certainly raises some questions.
Yeah, but we’re comparing academic psychiatry to criminology, not physics. I mean, the bar is set pretty low.
Two possibly relevant points:
1. When I was a graduate student, I roomed for a while with friend from high school who was getting a doctorate in psychology. He told me that he had asked one of his professors what the evidence was that psychoanalysis worked. The professor gave him cites to a bunch of studies, he read them, and concluded that about half the studies showed it worked, about half that it didn’t.
2. The idea of getting at the causes of crime/reforming criminals is not new. It played a large role in changes in the English legal system in the late 18th and early 19th centuries, in two forms. One was the idea of getting at causes, by cutting down on drinking, prostitution, gambling, low level crimes by minors that might lead them to more serious crimes, entertainments on which poor people might waste money and time.
The other was the idea of reforming those convicted, by solitary confinement (so they wouldn’t be corrupted by other prisoners), religious instruction, compulsory work/training. A penitentiary was supposed to be a place where people learned to repent their offenses, a reform school a place where they were reformed.
It’s an old set of ideas, in tension with the rational criminal model, in which you reduce crime by making it less profitable. I don’t think there is much evidence that the shift from a punitive to a reforming model actually produced the results that its supporters hoped for.
@Ted – “Can you point to any groundbreaking experiments in criminology and law? Has the field of criminology yielded any technological advances?”
Problem 1: Can you point to any groundbreaking experiments in Linguistics? Has the study of language yielded any technological advancements?
…Or maybe Language and Law are fields where the radical advances came a long, long time ago, the low-hanging fruit is all picked, and the breakthroughs now require massive investment and an as-yet unavailable tech base to achieve?
Problem 2: you seem to be making an implicit claim that Psychiatry can give improved outcomes for the general crime problem compared to criminology, law, religion, or basic common sense. Do you have any evidence to back that claim up?
FacelessCraven,
Linguistics? Did I suggest that linguistics competes with the criminal justice system?
I would look to the field of psychopharmacology if you want evidence for the ameliorative effects of drugs. Research on operant conditioning seems promising as well. Although overcoming the cultural inertia that stifles its implementation seems to be a problem. I think it’s far too early to claim that behavioural genetics is a dead end.
You’re right, we haven’t found our brave new world just yet, but does that mean we should just give up and put our faith in medieval institutions?
…yes and yes, actually. Big chunks of the theories of languages and automata in computer science draw on concepts originally developed in linguistics, and it’s far from clear that the technology would have evolved in the same way without them.
You have a solid argument in general, but linguistics is a bad example.
Nornagest – “You have a solid argument in general, but linguistics is a bad example.”
Hmm. Maybe Linguistics isn’t the right word? …We’ve had spoken and written language for a very long time. Spoken and written language are big, big technological steps up. I see no evidence that we’ve had any revolutionary progress toward “better” spoken or written languages in the last 2000 years, say. We’ve invented better tools that make speaking and writing vastly easier or more efficient, but the technology of the language and alphabet themselves doesn’t seem to have changed much at all, and doesn’t seem likely to. I’m not aware of features of, say, modern English that make it significantly superior to ancient Hittite or Persian or Chinese.
Does that seem true?
@Ted – “Did I suggest that linguistics competes with the criminal justice system?”
You’re comparing law and religion, two technologies that have been around for several thousand years, to psychiatry/psychology, which have been around something like a century. That seems roughly analogous to language (Linguistics was probably the wrong term), which has been around for several thousand years, versus, say, computer science, which has been around a bit less than a century. Computer science can facilitate and enhance language, but it is not even close to being able to replace it. Psychology vs religion/law seems similar. You were originally talking about priests and judges, right?
“I would look to the field of psychopharmacology if you want evidence for the ameliorative effects of drugs. Research on operant conditioning seems promising as well. Although overcoming the cultural inertia that stifles its implementation seems to be a problem. I think it’s far too early to claim that behavioural genetics is a dead end.”
If I understood it correctly, Your original claim was that psychology/psychiatry have tested and verified solutions available right now that dramatically improve outcomes for dealing with criminals compared to the current criminal justice system. I’m pretty sure that’s not remotely true, but I’d be happy to be proven wrong if you’d care to name specific interventions and provide some evidence. Theoretical, unproven and experimental techniques don’t count; we have criminals that have to be dealt with now, not ten years from now.
The only one I can think of would be treatment rather than incarceration for drug addicts, but you seem to be making a bigger claim than that the war on drugs is badly implemented.
If I understood it correctly, Your original claim was that psychology/psychiatry have tested and verified solutions available right now that dramatically improve outcomes for dealing with criminals compared to the current criminal justice system.
Different regions and nations have different criminal justice systems. Some of the differences in outcomes may be due to differences in their host populations, but I don’t think that’s the whole story. If you’re looking to reform the penal system in your region, you may want start by looking at comparison studies.
@Ted – “Some of the differences in outcomes may be due to differences in their host populations, but I don’t think that’s the whole story.”
…Any evidence to back that opinion up with? I’m pretty sure the field of criminology disagrees with you; an awful lot of them seem to claim that crime rates between countries can’t be meaningfully compared. Meanwhile, Americans kick more people to death per capita than Britons kill by all means combined, and the Japanese are virtually crime-free but unbelievably suicidal.
“If you’re looking to reform the penal system in your region, you may want start by looking at comparison studies.”
So that’s a ‘no’ to naming specific interventions, then?
Doctors are people, just the same as judges and priests and us. I see no reason to expect that they’d handle the criminal justice system any better than the judges. Further, if I were to pick a field to solve crime, I don’t think I’d pick the one in the middle of the Replication Crisis.
[EDIT] …Or the one that developed and deployed the lobotomy…
…Any evidence to back that opinion up with? I’m pretty sure the field of criminology disagrees with you.
I’m not sure I understand your question. Are you asking for evidence to support the idea that differing rates of crime are not entirely based on genetic differences?
So that’s a ‘no’ to naming specific interventions, then?
Are you genuinely asking for advice, or are you just nitpicking?
Further, if I were to pick a field to solve crime, I don’t think I’d pick the one in the middle of the Replication Crisis.
I’m not asking doctors to solve crimes. I just think people should get over the fact that psychological evaluations involve normative judgements.
@Ted – “I’m not sure I understand your question. Are you asking for evidence to support the idea that differing rates of crime are not entirely based on genetic differences?”
There are a lot of differences between the populations nations than the biological ones, so no. I am saying that Swedes, Britons, Americans and Japanese are not interchangable. Adopting Japan’s criminal justice system in america will not result in outcomes similar to Japan. I have no idea what outcomes it *would* result in, and I’m pretty sure you don’t either. I do suspect they would likely be bad ones.
“Are you genuinely asking for advice, or are you just nitpicking?”
You claimed that doctors/psychologists/psychiatrists are better at arbitrating morality than “priests, lawmakers, judges, and mobs”. That seems pretty obviously false to me, so I’m asking for specific examples.
“I’m not asking doctors to solve crimes. I just think people should get over the fact that psychological evaluations involve normative judgements.”
Offer some evidence that psychology’s normative judgements are actually superior to those of law or religion, or in fact are even based on empiricism at all, and I for one would be happy to.
FacelessCraven,
If we’re going to have moral authorities, I’d prefer them to be informed by science instead of gut feelings.
Drugs have to undergo an extensive series of trials before they’re introduced to the market. The standards for introducing laws are much more lax. Legislative bodies are not required to demonstrate the efficacy of their product before they administer it to the hapless public.
“If a lack of empathy leads other people to retaliate or have you arrested, it hardly seems like an optimal characteristic.”
This argument looks pretty circular? Replace “empathy” with “looks like a witch”, or any characteristic people are prejudiced against, and it still works.
Replace [lack of] “empathy” with “looks like a witch”, or any characteristic people are prejudiced against
If all I know about you is that you look like a witch, it tells me nothing about how you will treat me.
If all I know about you is that you lack empathy, well . . .
Well, what? Lack of empathy is a personality trait, it doesn’t necessarily mean you’ll be eating anyone’s dog or burning anyone’s house down. It’s often thought of as the central feature of stuff like antisocial personality disorder, but it won’t get you there on its own; any personality disorder is only a personality disorder if it brings clinically significant disruption to your life. And diagnosis for ASPD, in particular, usually involves a bunch of questions along the lines of “are you a habitual shoplifter” and “do you torture animals for fun”.
I don’t think we even need to get anywhere near dog eating or house burning or DSM-classified personality disorders. My point was that “prejudiced” means something. If I know that you lack empathy, that isn’t a prejudice, it’s an assessment.
Empathy is an emotion. It tells you nothing about behavior. Some people without empathy behave perfectly normally. Some do not, just like people with empathy.
And empathy itself is correlated with wild aggression when people feel it with some group or person they believe has been wronged. Empathy has been lauded as this great thing, but it’s just another emotion with a good and bad side.
Sastan, we can’t measure empathy in other people without referring to behaviour. Psychological assessment involves value judgements, not blood tests. I think some people think doctors are overstepping their bounds when they become arbiters of morality, but I’d rather have medical doctors in that role than mobs, priests, lawmakers, and judges. Provided, of course, that a doctor’s power to legally administer involuntary ‘care’ is limited.
@Ted
You are factually incorrect, there are dozens of tests for empathy that in no way involve behavior. Their validity is open to debate, of course, as with all psychometric testing, but it exists and has an extensive literature.
As to the rest, I’m a bit confused. You are hinting and dancing around an issue and won’t put forward a thesis. Do you or do you not believe that a lack of empathy is a mental illness? Do you believe that no violent crime can be committed without mental illness?
I’ve gotten that you think that doctors should be the philosopher-kings administrating all justice, but that’s not what we’re talking about.
You are factually incorrect, there are dozens of tests for empathy that in no way involve behavior. Their validity is open to debate, of course, as with all psychometric testing, but it exists and has an extensive literature.
Can you give me an example? Keep in mind that talking, writing, and typing are behaviours.
As to the rest, I’m a bit confused. You are hinting and dancing around an issue and won’t put forward a thesis. Do you or do you not believe that a lack of empathy is a mental illness? Do you believe that no violent crime can be committed without mental illness?
I’m open to the idea that some criminals are not severely mentally ill, but I’m not convinced that a majority of rapists and murderers would come out with a clean bill of health if they were thoroughly tested for axis I and axis II disorders.
I’ve gotten that you think that doctors should be the philosopher-kings administrating all justice
Is that really a charitable interpretation of what I wrote? I trust medical doctors more than I trust police or judges. The comparison came up because some people raise their hackles when they consider the fact that psychological evaluation can involve making normative judgements.
Do you or do you not believe that a lack of empathy is a mental illness?
The DSM V doesn’t list a disease called empathy deficit, but some disorders do involve empathy problems. Autistics often have problems with cognitive empathy, whereas psychopaths are said to lack affective empathy.
Lolreally Ted?
The act of filling out a survey is behavior that impacts whether or not one has the condition under discovery? Wouldn’t that mean all psychometric tests are only behavioral measures, and that you’ve managed to define yourself into very, very silly logical loop?
Ok, you got me. I’ve been trolled and wasted at least an hour on this. Have a nice day.
I’d complain about your continuing to equivocate about your thesis, but what’s the point?
Wouldn’t that mean all psychometric tests are only behavioral measures
Of course they measure behaviour–they’re not blood tests. I assumed that you were referring to a blood test or MRI or at least some biomarker when you disagreed with my statement that empathy can’t be measured directly. What test did you have in mind?
I only said that the argument was bad, not that empathy isn’t Jesus.
It just so happens that I think empathy is totally-not-jesus, but I didn’t bring it up in that comment: The structure of the argument “people at large do bad things to people with that quality” is simply a bad argument for convincing rational people. Whether that quality in question is “no empathy”, “highly empathetic”, or “serial killer”, the argument is 100% equally as bad, because it’s simply a misleading dressing up of an appeal to public opinion.
The very term “arbitrators of morality” comes from the old rule. It requires that the doctors choose how to arbitrate and we choose to accept it.
There’s a difference between being mentally ill and being an asshole.
Lack of empathy is certainly an issue with murderers. I’ve prosecuted a sophisticated financial murder, and an unsophisticated getting-high-is-more-fun-than-feeding-kid murder. Both of these people were broken in some way, but they were not mentally ill by any standard definition.
I’d note there’s also sometimes a confluence with being mentally ill and being an asshole; I have prosecuted those people, too. Just because you’re mentally ill doesn’t mean that your actions stem from that; plenty of mentally ill people don’t shoot others to get their drugs. In California, if you shoot someone because you think they are Satan come to steal the souls of the children, you may be not guilty by reason of insanity, but if your mental illness causes you think that guy at the bus stop has some cocaine for you to steal and you shoot him for it even though such a view is delusional, you’re in trouble.
But if we call everything mental illness, then we ought to have a treatment for those things. The treatment for the thief-murderer is… what? Talk therapy? There’s also an important deterrent effect of criminal sanctions for bad behavior, even for people who are mentally ill. Yes, there are people who are very crazy and who are driven predominantly by the illness; there do need to be allowances for that (Szasz was wrong.)
Finally, I always appreciate Scott’s posts on criminal law. Vox does enough to blow through any possible Gell-Mann Amnesia effect and makes me mistrust them entirely; Scott’s posts make me trust him a bit more on issues I am inexpert on. Yay.
I think there’s a difference between being an asshole and being a murderer. The tendency to commit murder seems to be an extreme sign that something is wrong.
If wanting to kill oneself qualifies one as being mentally ill, why doesn’t wanting to kill someone else qualify?
‘But if we call everything mental illness, then we ought to have a treatment for those things.’
I don’t think an illness needs to have a treatment before it can be considered an illness. Most mental illnesses are incurable. And why can’t locking someone in a padded room be considered a ‘treatment?’
Most schizophrenics, depressives, and psychopaths respond to incentives in some way or another, so I don’t think they should be exempt from the rewards and punishments that we give to people who we consider healthy.
http://lesswrong.com/lw/2as/diseased_thinking_dissolving_questions_about/
Killing oneself outright cannot accomplish one’s goals–or, in the cases it can, it generally isn’t considered crazy, ie, kamikazees, etc. Killing someone else (deliberately, rather than a “tendency” to do so) could; we aim to set up society so that the cost-benefit analysis there is clearly lopsided against ever doing so, but different people could come to different conclusions and merely be mistaken about relative odds of getting caught, etc.
Different moral systems, as well, of course, but is that an indication of insanity?
Insanity isn’t a term that’s used in modern medicine.
Never claimed to be a doctor.
considering suicidality to directly constitute a mental illness is crazy though. Or perhaps retarded.
I do think that wanting to kill someone else is (generally) way, way, crazier than wanting to kill yourself.
‘I’ve prosecuted a sophisticated financial murder, and an unsophisticated getting-high-is-more-fun-than-feeding-kid murder. Both of these people were broken in some way, but they were not mentally ill by any standard definition.’
I find that hard to believe. Are you sure that they had no paraphilias? No delusions of grandeur? No anxiety disorders? No depressive episodes? No schizotypy? No compulsive overeating? No addictions?
No dysthymia? No sleep disorders? No ADD? No manic episodes? Borderline personality disorder? Histrionic personality disorder? Avoidant personality disorder? Antisocial personality disorder?
Boanthropy? Meningial rockworm? Gassy? Is it gas? They had gas, didn’t they?
EDIT: Or, to be slightly less of a jerk – of course JRM can’t be 100% certain that they couldn’t be diagnosed with anything at all in DSM-V. But nor can you be sure that every murderer can be diagnosed with something in the DSM, and given that JRM knew these people and you are speculating, you should defer to his actual knowledge.
More generally, you are playing a silly game. Of course all murderers are mentally ill if you define them as such, but absolutely nothing follows from your re-definition.
Gas isn’t a mental illness, but still, it would be weird to claim that I prosecuted two people who never farted.
Look around you. Would you say that your coworkers are physically fit? Are they beautiful? Are they scrupulous? If the average person is flawed, then it should come as no surprise that people in prison populations have (on average) less-than-optimal brains.
Salem, I’m not claiming that everyone in prison is mentally ill. I just don’t have any reason to believe that there is a huge group of people who would be mentally healthy if they could just abstain from murdering and raping other people. When minor aberrant behaviour indicates mental illness, behaviour that is significantly anti-social should suggest something about a person’s overall well-being and deviance from standards of comportment.
I think people want to believe that the mentally ill are very different from us. When they picture mental illness, they imagine someone drooling in straightjacket, so it’s easy for them to envision a mentally healthy rapist or murderer.
Oh, come on.
The vast majority of murderers kill one person. Sure, Jack The Ripper or Fred West fit your model of “inability to abstain from murder,” and so can be presumed mentally ill. But that’s vanishingly rare. Most murder is contextual, and arises out of criminal activity or domestic violence.
To take a random example: Guenther Podola was the last person executed for killing a police officer. He was arrested for a very serious crime, and killed a policeman trying to escape. There’s no reason to assume mental illness as the cause when (perhaps mistakenly calculated) self-interest will do.
‘Oh, come on. The vast majority of murderers kill one person.’
A backpacker is traveling through Ireland when it starts to rain. He decides to wait out the storm in a nearby pub. The only other person at the bar is an older man staring at his drink. After a few moments of silence the man turns to the backpacker and says in a thick Irish accent:
“You see this bar? I built this bar with my own bare hands. I cut down every tree and made the lumber myself. I toiled away through the wind and cold, but do they call me McGreggor the bar builder? No.”
He continued “Do you see that stone wall out there? I built that wall with my own bare hands. I found every stone and placed them just right through the rain and the mud, but do they call me McGreggor the wall builder? No.”
“Do ya see that pier out there on the lake? I built that pier with my own bare hands, driving each piling deep into ground so that it would last a lifetime. Do they call me McGreggor the pier builder? No.”
“But ya fuck one goat..”
There’s no reason to assume mental illness as the cause when (perhaps mistakenly calculated) self-interest will do.
I never claimed that mental illness caused the crime. Mental illness is just a broad term that we use to label people who exhibit (some kinds of) aberrant behaviour. The label ‘mental illness’ isn’t specific about the aetiology of the behaviour. It indicates that the behaviour is is undesirable, though. I believe that we are all, to some degree, flawed to the core. It wouldn’t surprise me to find that criminals are more flawed than average.
Sure, they’re ‘healthy’ in the sense that they don’t have a label yet, but honestly… how healthy can they be if they ended up in prison? And how long will they stay healthy after years of imprisonment?
@Ted
This is circular logic, if you define health as “does not engage in criminal behavior” of course you are going to conclude that all criminal are mentally ill.
The problem you run into is that this is not how most people define it.
” The label ‘mental illness’ isn’t specific about the aetiology of the behaviour. It indicates that the behaviour is is undesirable, though. ”
That seems to imply that the norm is for someone to only take behavior that is desirable, hence any deviation is mental illness, which makes no sense to me.
Individuals have been “as if designed” by evolution to pursue their own ends, ultimately reproductive success, not the general good of society.
By your definition, is every politician who supports a policy because he expects it to get him votes or campaign contributions even though he doesn’t think it is best for the country mentally ill?
Al Gore, to his credit, has confessed that he supported biofuels because he was running for president and wanted to win the Iowa primary. Does that make him mentally ill? Does your judgement of whether he was mentally ill depend on whether you think biofuels are a good or a bad policy?
Carrying that further, imposing a carbon tax to reduce global warming is either desirable or undesirable. Does that mean that everyone on whichever side of the debate is mistaken is mentally ill?
David Friedman, complain to the editors of the DSM if you feel strongly about diagnostic criteria. Psychological evaluations are going to be normative judgements no matter how you slice them, though.
You could declare that the bottom 30% of the affect spectrum are dysthymic or you claim that the term should be reserved for the bottom 1%. What does it matter? Pretty much everyone could improve their affect.
Seems to me that there’s a fairly clear-cut distinction between a machine that was poorly designed (or is being operated outside of its design specifications) and a machine that has a faulty part. If you consider the mind as a machine, mental illness is the latter.
The distinction gets a lot less clear in the absence of a designer, especially when some of those problems have genetic origins or components.
It makes things somewhat fuzzier, obviously, but I don’t see it as a huge problem from a conceptual standpoint. Can you give an example?
In practical terms, in most cases I think we have a reasonable working knowledge of how the mind is supposed to work. Granted it has to based primarily on the assumption that any metaphorical “broken part” is only going to be broken in a minority of individuals … but I’m not aware of any cases where that assumption needs to be seriously questioned.
(I assume you don’t want a description of potentially legitimate reasons or scenarios to to murder or steal.)
A guess: “Mentally healthy” probably here means someone without a specifically labelled mental problem/disorder/complex/whatever.
‘(I assume you don’t want a description of potentially legitimate reasons or scenarios to to murder or steal.)’
Now that you mention it, I would like to see your list of legitimate reasons to rape and murder. I suppose we run into definition problems because murder is, by definition, unjustified. I suppose it’s possible for someone with an optimally functioning brain to be convicted of murder, but I would think that mentally healthy people would have a better shot at avoiding capture and conviction.
I think some people get cognitive dissonance from the idea that we are supposed to feel scorn toward criminals, yet have empathy for the mentally ill. Some mental illnesses are just as common as many non-mental illnesses. I wouldn’t expect many people to live for 80 years without experiencing some symptoms of mental illness, even if it’s just a minor aphasia, delusion, hallucination, paranoid episode, or depressive episode. It seems that some of the commenters here imagine someone who is babbling and insensate when they imagine mental illness, whereas I picture something more mundane, like compulsive overeating. It’s trivially easy to be diagnosed with a mental disorder. If the majority of prisoners haven’t been diagnosed with some disorder or other, I still wouldn’t assume that the majority of them have brains that are in optimal states.
I’m not saying that my definition of ‘mentally healthy’ is common. I view mental health as something that only occurs intermittently. It’s a description that I would reserve for people who are behaviourally exceptional, like being a good writer, or good at chess. Then again, I consider aging to be a disease (or rather, the process of senescence involves multiple failures within the body).
Now that you mention it, I would like to see your list of legitimate reasons to rape and murder.
For theft, the hungry man who steals a loaf of bread is perhaps the ur-example of justifiable crime and is common enough to be seen as a cliché. I have also seen utilitarian’s argue with an apparently straight face that they derive more utility from possessing X than Walmart looses to shoplifting ergo shoplifting is justified. Are they insane? probably not. Are they thieves? Absolutely.
For assault/murder, aggressive defense of oneself or others, or committing assault in an effort to prevent some other crime is often seen as a virtue. Likewise shooting a rabid dog is generally seen as doing everyone a favor, rather than animal abuse.
For rape, the whole purpose of the affirmative consent movement is to get rape reclassified to includes previously consensual, or at least ambiguous, behaviors to the point where it will be possible to be convicted of “rape” despite acting in good faith. In the same strain I also expect BDSM and other forms of “straight kink” to be criminalized or pushed further underground in the near to mid future unless feminism experiences some significant pushback.
I could go on, but I think you get the idea.
Unlikely. So far, BDSM folks seem to be the only group that understands what feminists are talking about, while the “normal” people are going “Well, she didn’t try to claw my eyes out / he didn’t punch me in the face, so it was consensual, right? What did you want, a form in triplicate? lololol”
Hlynkacg, I hope we can agree that the circumstances you listed are not representative of the majority of convictions.
@ Nita
Color me skeptical.
@ Ted
Maybe not the majority, but then that was not the objective was it?
@ HlynkaCG
http://ia801309.us.archive.org/2/items/gov.uscourts.vaed.314481/gov.uscourts.vaed.314481.45.0.pdf
As far as I can tell, this is not a case of a student being expelled for engaging in BDSM. It’s a case of a student being expelled for non-consensual sex with another student, where the BDSM aspect of the relationship determined only the phrasing (i.e., ignoring the safe word instead of ignoring the word “no”).
Maybe not the majority, but then that was not the objective was it?
In a way, it was. Your examples don’t support the idea that a majority of rapists and murderers would get a clean bill of health if they were thoroughly tested for axis II disorders.
@Nita:
For a more detailed account of the case in which the facts are less clear, see:
https://www.washingtonpost.com/news/volokh-conspiracy/wp/2016/03/04/court-george-mason-university-violated-due-process-while-expelling-student-for-alleged-bdsm-related-sex-assault/
And for a discussion of what the case implies about the constitutional status of BDSM, see:
https://www.washingtonpost.com/news/volokh-conspiracy/wp/2016/03/04/no-constitutional-right-to-engage-in-consensual-bdsm-sex/
@Nita
Read the Judge’s finding at the end…
TL/DR: The state can prosecute BDSM as “abuse” even when it’s consensual.
Edit: Ninja’d by David Friedman
@Ted
I suspect that a sizeable portion would, though at this point it feels like you’re moving the goalposts.
@ HlynkaCG
Basically, it says that kinky sex has no special status under the law, so it can be restricted on the basis of harm, like any ordinary activity. That seems in line with the current legal situation, and I’m not seeing any movement towards criminalizing BDSM (or any connection to feminism, for that matter).
As evident from the other article linked by David Friedman, the central dispute is about the internal complaint-handling procedures of universities, and that’s where the outcome will have an impact.
Nite: From the Volokh post quoting the decision: “Although Roe’s evidence of the July 2014 telephone conversation recording was to the contrary in that plaintiff responds that he did not stop when Roe used the safe word because he “felt like [she] could handle it,” plaintiff testified at his panel hearing that he was simply trying to be agreeable with Roe as part of his attempt to apologize.”
@Nita
I’m sorry but I think you’re whistling past the grave yard here. There is a movement towards lowering the threshold and broadening the definition of what constitutes “Harm” in the eyes of the state. And in that context the judge’s finding that consent is no defense is troubling.
@Nita: personally I found the wording worrying, particularly given that there’s historical precedent (in the UK, IIRC) for charging BDSM participants with being accessories to an assault against themselves. (Or so I’ve heard.)
“Now that you mention it, I would like to see your list of legitimate reasons to rape and murder. ”
What does “legitimate reasons” mean? Morally correct reasons? Reasons that serve society? Reasons that make logical sense in terms of the self-interest of the person committing the crimes?
Only the last seems to me to connect to mental illness. Pretty nearly everyone gives higher priority to his own welfare and the welfare of those he cares about than to the welfare of strangers. Does that mean that everyone is mentally ill?
David Friedman, you may want to ask Sastan, hlynkacg, or navigater. I’m not someone who has a clear idea of how a mentally heathy murderer would act.
The simplest example I can think of for a mentally healthy murderer would be a professional hit man. He kills because he gets paid to do it. He is sufficiently competent so he is very unlikely to be caught. He regards his victims as at best members of his outgroup, possibly enemies of his ingroup, so being willing to kill them is no more crazy than the willingness of someone in the military to kill strangers classified as enemies.
The same analysis would apply to someone who kills a person he has reason to strongly dislike under circumstances where he is very unlikely to be caught and gets some substantial benefit from the killing—eliminating a rival in love, inheriting property, or the like. His act may be wicked, but I don’t think it is crazy.
How much work is being done in your argument by identifying “not mentally ill” as “mentally healthy”? To my ear, “mentally ill” suggests mental problems more serious than those of most people, “mentally healthy” suggests a mentality in better shape than that of most people.
Might work as an example, but I’m pretty sure that the professional hitman — at least outside of a few people sponsored by governments or organizations that might as well be governments, and then we don’t usually call them hitmen — is a Hollywood invention. There are people that are willing to kill for money, sure, but they don’t fit the archetype.
@Nornagest – I think you’re right, but a drug dealer seems much the same in all the ways that matter: A person willing to hurt people illegally for financial gain.
@Marc Atwood
Speaking from 1st hand experience, they exist. Though as Nornagest says, they tend to be sponsored by governments or organizations that might as well be governments.
While there is fair amount of value in his observations on the effects of PTSD I also think that Col Grossman puts a bit too much stock in the Marshall study and his own theories about group-psychology and the army’s “mind control” abilities. He seems to get the distinction between violence addressed to specific individuals and “to whom it may concern” backwards and IMO that aspect of “not being right in the head” is a product more of our own society’s WEIRD-ness than aberration on the individual’s part.
Ted I was saying that I assume YOU didn’t want me to do that, -just mentioning the ambiguity of your phrasing, which was consistent with the possibility I was specifically saying that I guessed you didn’t intend. I didn’t say I thought someone could be a mentally healthy murderer. (I wouldn’t, because my definition of murder is “wrong-killing”.
Mark Atwood that argument looks fairly close to circular. Surely resisting mental trauma is a sign of good mental health, ipso facto? So one has to delineate in which cases it’s a sign of bad mental health. Imo these cases can be modelled as cases in which someone such should “break down and catch fire”, reevalute their whole life, and dedicate it henceforth either to charity or a noose.
Imo the important point is the distinction between killing and murder. Killing is by default wrong, but it can be the best of bad options, and it can even be straightforwardly right, e.g. assassinating hitler (he got really lucky in avoiding death by this means. I’ve heard it argued that this was a good thing in the end/on net though on the basis that he was an incompetent commander.)
It’s not wrong to e.g. kill someone in the process of defending someone, if the odds were not sufficiently in your favour that you could afford to go for a specifically nonlethal ending of the threat to an innocent/citizen. (whether such a level of circumstance is necessary for it to be not wrong to kill in defense of oneself or others, is another question, but I think the case I outline is unambigious and unontroversial, even if uncomfortable). If someone were to kill an attacker in such a circumstance, it would be a sign of good mental health for them not to be traumatized by it.
Conversely, killing someone for personal convenience or gain is straightforwardly, basically definitionally, wrong -It’s exchanging a relatively small gain for oneself, with a massive loss for another person, one that dwarfs the gain one gets. (there’s also the negative societal externalities of murder for gain, which may be even more significant)
So I think the problem is with people who collapse the distinction between murder and killing so as to consider it all to be “just-killing”, i.e. “not-murder killing”, or justifiable, not-wrong killing.
But imo in that case this hitman character is not so much mentally unhealthy as philosophically or morally unhealthy. Their “emotional balance” may be very stable in whatever objective ways can be measured. They may be kind to their friends and their dog -they just think that killing people for personal gain is ok.
I specifically left out rape because there’s never a good reason to do it. I was hoping you would recgonise that it’s in a different class than stealing and murder. (lol)Imo not recognising that would be a pretty bad sign if I wasn’t fairly sure it was just a relatively minor case of frivolousness.
Stealing is easy, even an unambiguous case springs instantly to mind: Stealing from the nazis to aid the war effort.
Murder has a definitional problem, yes. I meant scenarios in which the legal definition and the semantically-faithful meaning of “wrong-killing” might be in contradiction. I’m not going to bother listing one for this as it could start a fight but I trust we all agree that there is in principle a distinction between law and morality. (And by “we”, I mean all people with whom I’m willing to discuss moral philosophy by choice). However yes, that’s less a question of scenarios and more a question of definitions and classification choices (like some people hold that doing a bad thing is never right, even if it is clearly the best thing in the circumstance, because it’s still bad. I don’t agree but I have never seen a logical refutation of that viewpoint).
“If emptying the mental hospitals didn’t cause the murder rate to hike, what’s the common cause between the two?”
1960s liberalism.
The Warren Court, the Great Society, civil rights, LBJ’s 1964 landslide, the Kerner Commission, etcetera etcetera … It was in all the newspapers at the time.
For example, consider the career of Ramsey Clark, progressive paladin:
https://en.wikipedia.org/wiki/Ramsey_Clark
Note that Clark was Attorney General of the USA from 1967 until early 1969!
For a general history of the 1960s, see “The Unraveling of America: A History of Liberalism in the 1960s” by my old professor Allen Matusow.
The causal relationship is that 1960s liberalism caused both the criminal justice system to get softer on crime (which led to increased homicide, mugging, and burglary), and the mental health system to turn against locking up crazy people in asylums (which led to increased numbers of bag ladies).
Eventually, voters rebelled against government officials like Ramsey Clark being soft on crime. On the other hand, the mental health system has not gone back to locking up old ladies who hear voices into asylums.
The problem with Harcourt’s graph is that three things happened simultaneously in the 1960s:
– A. crime increased
– B. institutionalization of the non-criminally insane decreased
– C. imprisonment for crime decreased
Which is more likely to have contributed more to A? B or C?
C seems more direct in theory. You can also check it from two perspectives:
– Deinstutionalization has never been reversed, and yet crime fell after the early 1990s. In contrast, deincarceration was reversed.
– The demographics of institutions and asylums are quite different. Mental institutions tended to be populated by older people of both sexes with whites heavily represented. Prisoners tend to be very male, younger, and blacker.
The problem I have with this explanation is that it gets the order of events wrong. The decrease in aggregate institutionalization from 1955 to 1973 was not driven by a decrease in imprisonment (i.e. softening on crime), it was driven strictly by a decrease in mental hospitalization.
On the other hand, The Great Northward Migration did happen in the correct timeframe. Is there a way for that to be at fault for the decrease in mental hospitalization?
“The decrease in aggregate institutionalization from 1955 to 1973 was not driven by a decrease in imprisonment (i.e. softening on crime), it was driven strictly by a decrease in mental hospitalization.”
No, the crime rate shot upwards from about 1964 onward, yet the imprisonment rate continued to drift downwards, so the likelihood of being imprisoned per crime committed skyrocketed in the late 1960s.
This is basic social history 101 — see references in movies of the era to not being able to walk in Central Park due to muggers.
The increase in the homicide rate from, say, 1964-1975 was also seen in increases in muggings, car theft, and burglaries. The 1960s crime wave was very, very real, and it drove huge changes across America, such as suburbanization.
Is that attributed now as the primary cause of the spike in murder rate?
If so, would that lend positive evidence for the FBI’s statement that the current protesting of the police force is the cause of the spike in murders the past two years?
It is a matter of controversy. I for one prefer the lead poisoning theory, because banning TEL has been correlated with falling crime in many countries.
In America, at least, lead was in our gas and in our paint for a looooong time without any problems until the Great Northward Migration, and the population boom. Why weren’t we seeing ridiculous spikes in crime amongst white people who lived in areas with a lot of lead before blacks moved in? Why don’t the people in the predominantly white Superfund sites – with environmental lead levels dwarfing what you found in homes with lead paint – behave like Cthulhu cultists, if lead is the driver? “lead caused it” doesn’t add up.
Less people, less wealthy, living less densely means less exposure to leaded fuel.
And if you’re talking about the Second Great Migration, the one that happened in the mid-20th century, the interstate highway system was getting built out about that time. People drove much less before it was complete.
Heavy-metal contaminated sites are an interesting point, though, and one that I wonder if there aren’t statistics for.
Well, Scott, I’m glad you’re finally tackling that graph, since I’ve been waiting for someone to address it since I saw it in Harcourt’s paper two years back, but the version you have posted there leaves off the most damning element, which is the tight inverse-correspondence to homicides.
Page 19 here overlays the trends. If emptying the mental hospitals didn’t cause the murder rate to hike, what’s the common cause between the two?
That’s really interesting. Note the different denominators, so it looks like each person deinstitutionalized commits 1/100th of a murder/year. But that would mean over a 20 year period there’s a 20% chance each deinstitutionalized person would commit murder, which is definitely not what other people find.
It would also suggest that reinstitutionalization (in the form of mass incarceration) is driving the current reduction in crime, but that’s not what anybody else has found, see eg this article.
Likewise, if the severely (institutionalizably) mentally ill are only responsible for 10% of homicides, it’s hard to see how the institutionalization and homicide rates could correlate so nicely.
Have we considered blaming the decrease in mental hospitalization on the increase in the murder rate?
Plenty of people have found a link between incarceration and declines in violent crime. See for example this piece by Stephen Levitt which ascribes one-third of the decline in crime rates in the 1990s to increased incarceration:
http://pricetheory.uchicago.edu/levitt/Papers/LevittUnderstandingWhyCrime2004.pdf
It is easy to play a lot of games with this data because you get your variance from a bunch of correlations between crime and incarceration rates in jurisdictions marked by lots of migration, with plenty of reverse causation issues, etc. You cited the Brennan Center study; they are a pretty biased source, as you can tell right from their name. They even say in their mission statement that one of the aims of their work is ‘ending mass incarceration’.
What if you try switching it around? It’s not that crazy people released into the community committed more murders, it’s that murders that would formerly have been classed as acts by a mentally ill person and get them sent to a mental hospital instead of prison are now – because the large institutions are being closed down and you can only send them to jail – are being counted as ordinary murders.
Mmmm. I think I had a point there before that sentence petered out at the end; maybe it’s more that “criminal who’s not mentally ill but commits impulsive crimes might formerly have been sent to a mental hospital but now is on the streets and gets the chance to scale up to crimes like murder committed in the course of a robbery or a street fight”.
Has there be a decrease in the rate at which people are found “not guilty by reason of insanity”? I know it’s not a very successful plea.
If the background rate of murder (those committed by the non-mentally-ill) remains unchanged, then the correlation of “murder rate” and “deinstitutionalized population” would correlate highly, even if they are only committing a small percentage of murders. Correlation doesn’t imply an intercept of zero.
I too find this one much more interesting. The graph from Vox shows a 15-20 year delay between the changes, which felt too long.
Can anybody else control your brain or thoughts?
Yes. (My wife and other close family and friends)
Do you ever hear voices other people don’t hear?
Yes. (I listen to podcasts)
Do you ever see something that other people tell you isn’t real?
Yes. (I see that the EU is on course to become a single federal state, which many in the UK say is not not happening)
Do you ever think anyone (other than correctional staff) is spying on you or plotting against you?
Yes. (I play Risk sometimes)
I also answered the questions very pedantically. I’m having flashbacks to when I was in high school and looking for work. One screening procedure had a short quiz which included the question, “How many days are in a year?” Apparently, 365.25 was not acceptable and made me less qualified for employment. It’s nice to know that I’m also severely mentally ill.
365.25? Pope Gregory would like a word with you.
Proposal: Pedantically answering questions like this, where there’s another answer that’s clearly expected (and when the test is actually given by someone with power to institutionalize you), might indeed a sign of mental illness.
So all the patients that Scott described, who say that they are being spied on because they know that the NSA spies on everybody, are showing signs of mental illness?
I’m not sure how useful this terminology is (q.v. Solomon and whales), but… maybe? If a psychologist asks “Are you being spied on?” perhaps a truly well-adjusted person will understand that he’s implicitly excluding the NSA and answer “No.”
Or, at least, it’d be statistically associated with being well-adjusted.
Certainly most neurotypical people would ignore stuff like the NSA, the Web filters at work, etc. But even if the question’s filtering against normality, it’s going to be scoring for the wrong kind of abnormality: paranoia or some other sort of delusion, rather than being excessively literal or just being a smartass.
There are situations where you don’t want to hire a smartass, but I doubt the test’s designed to handle them.
A 125 IQ SSC person will probably be able to recognize that the spying question is not meant to include the NSA. Would the average person off the street, especially one unfamiliar with questions like that in general?
(And what if he concludes “this is a trick question” and answers yes because he doesn’t want to “fall for the trick” by excluding the NSA?)
Sure. This is exactly the kind of contextual cue that normal-IQ, normal-neurology people take into account all the time without realizing they’re doing it. Most likely they won’t even think of the NSA.
A possible steel man of the “we need more state-run mental hospitals” argument:
1: The entire point of the judicial system is to have less crime
2: Some people will commit less crime if they are given treatment
3: Therefore such people should be sentenced to treatment rather than prison after committing a crime
4: In order to do this we need to have enough state-run treatment facilities to accommodate the number of people needing said treatment.
5: The fact that old facilities were horrible does not mean we shouldn’t build and staff good ones.
This seems entirely sane to me.
The nature of nonconsensual confinement pretty well precludes “good ones”. People are incapable of doing this. It brutalizes both the staff and the inmates. Prisons are the way prisons are not because we didn’t “build and staff good ones”, but because people are people. So too with the old mental institutions.
Unless your claim is that only Americans are people, this is blatantly false. There are plenty of countries in the world that manage to run much more humane prison systems than the US.
No one is perfect, but there is a lot of room for improvement in the US prison system, and a lot of that is really low hanging fruit.
“Better than the US” and “Conducive to mental health” are not even in the same ballpark. Yes, the US could improve its prison system, and should. No, this does not mean that we can reinstitutionalize a substantial fraction of the US population without massive problems.
The homicide rate, our most reliable single indicator of total crime rates, really turned up around 1964 while the prison population was dropping:
http://isteve.blogspot.com/2005/04/introducing-crime-misery-index.html
The simplest model is that there was an exogenous growth of liberalism in the postwar era that really started to kick into gear institutionally exactly when it seemed like at the time: around JFK’s assassination and the Beatles appearing on the Ed Sullivan show. This led to emptier prisons and mental asylums and more crime in the streets.
Eventually, the trend toward being softer on crime was reversed and subsequently crime rates fell. But our society hasn’t changed back on mental asylums.
The homeless began appearing on the streets in sizable numbers at the end of the 1970s, probably due to a combination of deinstitutionalization and all the drugs people had taken over the previous 12 years or so.
I can pinpoint my first awareness of the modern homeless problem to right after the movie “Annie Hall” came out in 1977. I can recall being puzzled by a New York magazine’s joking reference in 1977 or 1978 to Diane Keaton’s style of clothes in “Annie Hall” being inspired by the “Bag Lady Look.” I didn’t know what a “bag lady” was at the time. The idea of women living outdoors like an old-fashioned winos was unfamiliar to me at the time. But I started to notice more and more bag ladies on the streets during the rest of the 1970s. Of course, when Reagan came into office in 1981, then homelessness became an official problem in the media. But it was definitely growing in 1978-1980.
Googling, I find a Sept. 19, 1977 issue of “New York” that says, “Women lawyers … don’t want to go to work dressed as “Annie Hall,” Kenzo’s bag lady, or a St. Laurent fantasy.”
So I may have misread that in 1977, dropping the unfamiliar name “Kenzo.” But from all the subsequent references to “Annie Hall bag lady look” I find on the Internet, it looks like other people did too. Diane Keaton complains in interviews to this day that people accused her of dressing like a bag lady in her Oscar role.
But the point is that when I read this in 1977 I was unfamiliar with the concept of a “bag lady.” But I can very much recall noticing a growing number of example of this term over the 1978-1980 era.
The Vox graph of deinstitutionalization explains a lot about why Americans started to become familiar with the term “bag lady” in the late 1970s. It probably doesn’t explain much about why Americans agreed to build more prisons at vast expense.
For the consequentialists in the room
Suppose that the two alternatives for these people really are long term street homelessness or institutionalization
Which option generates more utility for the patient? For everyone else?
That’s a tough question, because it probably depends on how many of the chronically homeless are truly untreatable vs. how many could be institutionalized for awhile, cleaned up, etc. and become productive members of society. The number of hopeful cases is probably not zero – a big issue is that a lot of times there are helpful resources available but the person is either unable or unwilling to take advantage of the resource – but it’s probably not huge.
If you’re really down to “leave them homeless forever” or “lock them away forever” though – the latter option probably leads to a longer but still fairly miserable life at huge financial cost to the rest of society.
Heck, how many of them would, on facing the real chance of institutionalization, pull up their socks without it?
It’s certainly higher than zero.
That’s also around when I’ve been told that rooming houses were made illegal– it would definitely be worth checking on whether a lot of “substandard” housing was eliminated.
The way some young liberals pine for the healthy state of unions in the 1950’s, I wonder if getting a room at the YMCA for a dime was really as simple and reliable as it seems in stories from that time?
I’ve tried to help out a very normal (had had a job, never took drugs) person find housing for a couple days to a week. According to the YWCA it would require months of waiting on the waiting list, and even then they couldn’t guarantee anything. Meanwhile it was clear some residents had been using that “temporary” living arrangement for years, without ever finding a way out.
It seems like the support system we’ve designed has perverse incentives: if you show up and speaking coherently, and have a look in your eye that says you’ll quickly find a job / stable living situation, it puts you at the bottom of the list for help. It seems like there could actually be more “normal” homeless at any time: served divorce papers from their wife, living in their car, etc…
But there’s no grant money for that, and even if it were, you wouldn’t need much. So instead the social safety net institutions seem to try to one-up each other for the number of problems their residents can have, creating a living situation that are basically unacceptable to anyone with personal expectations of recovery.
Is there a Rates of Institutionalization graph which is broken down by demographics? For example, one graph showing rates of institutionalization (in mental hospitals and in prisons & jails) for 18-45 year old males, one graph for males aged 46+, and one graph for women. I expect the curves would no longer line up.
Right, mental asylums in the old days had a much higher ratio of white women to black men than prisons have today. So, that comparison undermines the Vox thesis.
“100% a coincidence”?
This is not a coincidence because nothing is ever a coincidence.
“Lopez himself wrote a nice piece on how most mentally ill people are not violent, and another nice piece on how most people in prison are there for violent offenses. But put these together, and you get that most mentally ill people do not end up in prison.”
“most mentally ill people do not end up in prison” does not actually follow from the previous two points. It can be the case that most mentally ill people end up in prison but the number of people in prison for violent offenses is far greater.
“t most mentally ill people end up in prison but the number of people in prison for violent offenses is far greater.”
Most mentally ill people who end up in prison probably do so for violent offenses.
“Lopez himself wrote a nice piece on how most mentally ill people are not violent, and another nice piece on how most people in prison are there for violent offenses. But put these together, and you get that most mentally ill people do not end up in prison.”
Wait, that doesn’t follow. I’m just nitpicking because you probably meant “it suggests that” by “you get that,” but I’m posting about it anyway on principle.
How would you propose dealing with street bums? When people complain about deinstitutionalization, this is often what they’re really complaining about. Although street bums are often referred to as “the homeless”, this is misleading because it implies their biggest problem is not having access to housing. In fact, almost all of them are either seriously mentally ill, and/or are addicted to drugs or alcohol in a way that severely impairs their ability to get along in normal society. This makes sense when you think about it: ordinary people who fall on hard times can usually, if worst comes to worst, move in with family members or crash on a friend’s couch. That’s housing insecurity, and it can be brutal and humiliating, but it’s not “homelessness” in the sense most people use that term. To end up out on the street, someone either needs to alienate every member of their support network, or not have one to begin with. That usually takes seriously crazy behavior.
It’s hard to avoid the conclusion that many street bums need to be in custodial care of some kind, whether that is officially called a “mental institution” or not. Shelters clearly don’t work. Just giving them housing wouldn’t work, even if we could do it without creating perverse incentives. (How do you explain to someone working two jobs to afford a shared studio apartment that we just gave free housing to the drug-addicted bum on the corner?) A universal basic income would avoid the perverse incentives, but still wouldn’t stop them from blowing every check on booze or drugs and still having no place to sleep except the street.
These are all very basic social policy and welfare questions, all which have been hashed out in one way or another in scholarly articles. You should do some looking around on Google for papers instead of asking these questions here. I think you can guess what kind of homeless Scott’s referring to.
Shelters do have good outcomes, but reassessing things like studies on cost-benefit analysis and implementing new plans is what’s difficult.
why can’t he ask these questions here?
this is a obnoxious reply, and almost exactly the downside to the thought that Scott laid out in his last post
If you have a link that seems on point, or a search term that seems on point, that’s helpful to provide
just saying “hey, google it” to someone who done their wondering out loud is obnoxious
An obnoxious reply to an obnoxious set of reasoning that seems to expect others to do the legwork of explaining why something is difficult. We’re here to talk about rationality and using information correctly. If information is already out there you shouldn’t try to engage the topic with prejudice, as you only really seem to be intimate with the issue only so much as you’ve seen some homeless people around. Here’s a good one, read it if you want to learn:
http://digitalcommons.salve.edu/cgi/viewcontent.cgi?article=1088&context=pell_theses
re-reading the original post you were responding to, he could have phrased his thought process more delicately/(respectfully) [I suspect the people being described as ‘street bums’ would object to be referred to as such]
the question of how trends in MH institutionalization interplay with the population level of homeless people seems entirely on point
if you’re more well versed in the issue than the layperson, you’re well positioned to make our discussion better
The link you provided seems informative, thank you for providing it
“We’re here to talk about rationality and using information correctly.”
Why do you think that? This is not LessWrong, this is a private blog. I’m fairly sure we’re here to talk about whatever happens to be the subject of the article at the top of the page.
Granting for the sake of argument that JDG1980’s post consisted of primarily or only basic social policy and welfare questions which have been hashed out, lets say thoroughly, in scholarly articles, then so what? Then what was wrong with JDG1980’s post?
As to your post:
1. Scholarly articles aren’t Jesus
2. I haven’t read them, and probably JDG hasn’t either, if they’re so conclusive, and he’s so wrong.
(2a Reading presumably dry scholarly articles also isn’t a requirement to post here.)
3. Are you sure there’s even a consensus?
4. If there is a consensus, is it obviously right? No potential that it’s politically motivated, otherwise degenerate, or otherwiseconfounded? e.g. Is it straightforwardly empirically or logically settled? -Because there being a consensus in one field isn’t a reason to try to stifle opposing points of view, with rudeness, even if they assert things without prepending “I think.” (as much as we should hang people for not doing that, the glorious oncoming epistemelogical/judidical revolution is some centuries off I think.) Anyway, if there are such articles, please point in a direction, instead of just weaving a pose to imply that any toddler should know these things, and if they don’t they ought to keep their mouths shut.
5. Maybe JG was putting something forward, at least partially for the purposes of discussion, rather than to demand answers to questions. For example someone could have posted in response saying, “I don’t think that’s right at all…” and something could be learnt one way or another.
6. Someone being wrong out loud about something isn’t a particularly big deal. -It doesn’t warrant this level of rudeness. Personally I find the idea that shelters straight up don’t work somewhere between ludicrous and meaningless, but it doesn’t matter if someone is totally wrong in this context. If I want to argue the point I can. What I shouldn’t do is attack someone just for voicing and sharing some thoughts. Being wrong in good faith, involves 0 wrongdoing, there are precisely 0.00 (morally) wrong things involved in good faith wrongness. Further, it’s a tradition to for the sake of civil discussion treat things as good faith unless it’s heavily implied or proven otherwise, rather than look to root out all cases of bad and imperfect faith. It’s more practical to let things go 60-40, or 70-30, than 50-50, because subtle (and therefore heavily restricted) bad faith can be handled by civil conversation, while wrong accusations of same (including implied ones, and other inquisitions) are far more prone to causing the breakdown of civil discussion.
7. Even if it did, in terms of proportion, warrant hopefully-deliberate rudeness, it’s a bad strategy, because if one person is acting civil, but ignorant (or even subtly malicious), and the other person is going “ugh, learn your fucking 2 times table before you open your mouth”, then, all else equal the person who is acting civil, or appears to be, is the person who looks like they’re on the side of right.
TL:DR, more of an effort, please
You may want to refer to this https://slatestarcodex.com/2016/03/06/against-interminable-arguments/
Why? Could you be a bit more specifically bitchy?
Miles Davis’s autobiography includes a chapter about how he moved to New York City as a very young man in the 1940s, and almost immediately his musical idol, Charlie Parker, asked if he could stay with him for awhile due to girlfriend problems. Davis thought he was really living the dream.
Then he started finding out why Parker had nobody else to live with. He looks in his closet one day and all his new suits are missing. Parker had sold Davis’s clothes for drugs. Then Davis comes home another day and finds Parker nodding off on the floor — he’d sold Davis’s couch for heroin.
It’s much more likely that emptying out mental asylums correlated with growing homelessness.
Likewise, emptying out prisons during the Warren Court era correlated with growing rates of violent crime.
Conversely, higher rates of imprisonment in the 1980s correlated with lower crime rates in the 1990s, although that took awhile to manifest itself in overall crime rates. If you look at crime rates by age, you can see that JQ Wilson’s incapacitation theory worked pretty quickly. The homicide rate among men over 25 started dropping in the 1980s as more career criminals got locked up. But there was a spike in violence among teens during the crack era around 1990. By the mid-1990s, however, mass incarceration was driving down crime among all age cohorts.
I hate this condescending usage.
I did look and I saw the opposite. Maybe the problem is that you didn’t look? If you weren’t blind, you’d see the truth. How does that usage make you feel?
To see homicide offending rates by age, you can look at Figure 4 in this report on homicide rates 1980-2008 from the federal Bureau of Justice Statistics:
http://www.bjs.gov/content/pub/pdf/htus8008.pdf
Look at the graph in the article. The incarceration rate was pretty flat (actually increasing slightly) when Earl Warren was Chief Justice (1953-69).
But the crime rate went up, so the imprisonment/crime ratio went down in the 1960s.
Check out this graph:
http://isteve.blogspot.com/2005/04/introducing-crime-misery-index.html
Advocating that we send mentally ill homeless people to state run institutions is functionally the same as advocating that we criminalize homelessness (by whatever definition of homelessness that you want to use.
Is this a problem though? We criminalize things that we don’t want people to do, and we don’t want people to be homeless.
We criminalise things that we both don’t want people to do and think that we can effectively disincentivise by the threat of criminal penalty. We don’t want people to have broken ankles, but we don’t make it a crime to have a broken ankle, since most people are already quite strongly incentivised to not go around deliberately breaking their own ankles.
To the extent that homelessness is mostly a result of bad luck rather than a deliberate desire to not have a roof over your head, criminalising homelessness would not serve much good.
On the other hand, to the extent that there do exist people who freely deliberately choose homelessness over supporting themselves enough to afford somewhere to stay, then we can talk about disincentivising that. But I am skeptical that that attitude is at all common (at least among people who lack other pathologies that would complicate the picture).
In principle any homeless person could easily manage to get a criminal conviction and therefore go to prison, where they would have a roof over they head and three meals per day. In practice I have no idea how tough and humiliating prison life is, but I suppose that it is better than starving or freezing to death on the street.
So given that, at least in principle, homeless people have a way out of their lifestyle, the fact that they are homeless means that they either deliberately choose to be homeless, in which case you could disincentivise them by making homelessness a criminal offense in the first place, or they are incompetent to choose, in which case they would qualify for involuntary commitment to a mental hospital, rehab center or other custodial care institution.
“In practice I have no idea how tough and humiliating prison life is, but I suppose that it is better than starving or freezing to death on the street.”
The reverse seems quite plausible to me. Google some prison rape statistics in the U.S. for just one reason why. Also, some people value their freedom; imprisonment in and of itself can be intolerable for some people.
Certainly it may be true that homeless people choose their lifestyle — but not necessarily because they have “better” alternatives that they just elect not to pursue. A choice between a shitty situation and a much worse one is still a choice.
That’s one model. Another common model is that we criminalize things we don’t want people to do. For example, leaving your infant in the car such that it overheats and dies can get you prosecuted, despite the fact that people are much more strongly incentivized not to do that than they are to avoid deliberately breaking their own ankles.
I’m also sceptical that it’s all that bad
@Michael Watts
> Another common model is that we criminalize things we don’t want people to do. For example, leaving your infant in the car such that it overheats and dies can get you prosecuted, despite the fact that people are much more strongly incentivized not to do that than they are to avoid deliberately breaking their own ankles.
I’m not sure this example holds up. There are indeed those that _do_ want to kill their infants (i.e., infanticide); the laws are there for the people who want to commit that crime, are self-evidently not disincentivized to do so, and are thus in need of additional disincentive (the threat of punishment) to be discouraged from doing so. The unfortunate souls who have a moment of absentmindedness[1] and suffer this tragedy are already presumably disincentivized enough by the death of their child that having it also be illegal has basically nothing to do with setting their incentives.
[1] I read a long, excellent article on the people who’ve gone through this, both the psychology of the incident and its aftermath. I can’t remember where it was, but Google “forgotten baby syndrome” lest you think that incidents like this are always caused by undue negligence.
http://www.washingtonpost.com/lifestyle/magazine/fatal
This may be the article you were thinking of.
No, we criminalize things we want to punish. Homelessness is something we want to fix. We want people to not be homeless, but we want to use tools other than the big hammer of the justice system to stop them from being homeless.
As an analogy, we don’t want people to be sick, but we have no laws against having a heart attack.
And if an ambulance hauls off a person having heart attack to the hospital without being asked first, you haven’t “criminalized” heart attacks even though you’ve deprived the victim of some degree of personal autonomy.
Likewise, taking custody of a homeless person who cannot care for themselves need not be “criminalizing”. That’s actually kind of the point: the argument is for an option between “ignore it and hope they stumble into a community health clinic” and “put them in jail with violent criminals”.
“we have no laws against having a heart attack.”
No, but now that the ACA exists we do have laws against not being able to have a heart attack treated.
That would be the Emergency Medical Treatment and Active Labor Act, passed in 1986.
@DensityDuck:
There have been laws requiring hospitalsa and ERS to treat emergencies or critical problesm for *decades*. The ACA did very little in that regard, other than give people heart attacks when they saw how much their insurance costs were going to rise.
Until Medicare/Medicaid there were networks of charity hospitals, state and country run facilities and one could *almost* always get treated. Yes, there were holes in the system, and yes, people occasionally fell through the cracks, but by the late 1970s if you called an ambulance or got to the ER with a serious problem you *were* treated.
In the late 80s the (state run) hospital I worked with was writing off over 5 million dollars a year in indigent care while at the same time being the class 1 trauma center of choice for a two or three hundred square mile area.
You got to the doors, you got treated. You might have to have a chat with billing at the end of it to make payments, but at the time as long as you were making *a* payment you couldn’t be sent to collections. That payment could be a trivial amount, but as long as it was what you could afford and you kept paying it you got treated.
The ACA didn’t do *squat* in that regard. If anything it made it worse by making reasonable health care unaffordable for a lot of middle class families. I know it’s much harder for my family to afford medical care now–we’re covered against catastrophic problems, but getting blood work done, seeing a doctor for preventative measures? For us the sort of insurance that would allow that is far more expensive than we can afford, so we’re not getting the preventive care we could be.
As an analogy, we don’t want people to be sick, but we have no laws against having a heart attack.
Give it time.
From the WHO factsheet on obesity and overweight (bolding mine):
“Sustained political commitment” and “policies and actions” can easily move from “education campaigns” and “awareness raising” to “punitive measures of last resort”.
If the “carrot” of nagging public health promotions about Diet! Healthy eating! Exercise! Fat is ugly and nasty and unhealthy! You are leeching limited public health resources from genuinely sick people who didn’t make themselves ill by stuffing their fat faces! doesn’t work, do you really think the “stick” of punitive measures won’t be at least suggested?
“You had a heart attack/developed diabetes/osteo-arthritis because of obesity, which is preventable and avoidable; you knew the right diet to eat and the amount of exercise to take; you didn’t do this. Therefore you are culpable and if you don’t pay the surcharge fine for the medical treatment we had to give you, you’re going to prison for non-payment of fines”.
Social attitudes like that are already in place; a Tumblr user ok2bfit had a post about her “fit, healthy mother” who works as a hospital care assistant and who as part of her duties has to take care of a morbidly obese man, and it makes her “wretch (sic)” to go in and bathe him, and she hurt her back taking care of obese patients, and the poster thinks this is disgusting and wicked and she’d rather die than let herself get to that state.
“There have been laws requiring hospitalsa and ERS to treat emergencies or critical problesm for *decades*. ”
You didn’t understand the post; re-read it.
It’s not about treating a heart attack, it’s about having a heart attack.
Obligatory:
being homeless is something you are, not something you do
Not any more than being a home-owner or a renter is. insofar as they are statuses, they arise from your deeds.
Mary, I have no idea what you think you just read, but “BEING” homeless, remains a state of.. “BEING”, not an action. This is FAIRLY BASIC ontology/grammar/semantics.
/thought.
There is an entirely distinct class of occurence, “Becoming homeless”, which might bear some passing resemblance to a thing that occasionally consists of a single action, as in, a deliberate decision to become homeless can very rarely, technically, result directly from a single action, but of course even in that very rare case there remains a pretty important context in which that decision occurs, so equivocating even that tiny subset of this entirely distinct concept with a simple action is still highly misleading, because that single action is not the whole causal structure which gave rise to the homelessness, just the last point on it, at which it happens to narrow to the point of a decision in such a case.
Such bad phrasing can arise from actions by the way, though generally on a smaller scale than those things we generally call actions, e.g. things like carelessness or being in a hurry. Incidentally, that point applies to homelessness as well, though more with “actions” like “lacking motivation”, “PTSD”, “having brain damage” etc. Not really actions one “takes”, persay, but sure, kind of, technically, sort of, not really-at all, “actions” they can technically, obliquely, be categorised as -should their be some pressing need to push irregular polygons through round holes.
This is pretty irrelevant, but “Insofar as they are statuses” seems to be pure window dressing too. It seems obvious that they are 100% statuses, and on top of that there’s no principal of statuses that says they arise solely from (single) actions. Maybe on that point I’m understanding the word “status” in a different way than it’s meant, though.
Grammar does not in fact dictate ontology, as witness that literally anything can be cast as “being TERM”. If I go for a walk, I am being a person going for a walk, making “a person going for a walk” a status by that argument.
And my going for a walk likewise might arise from a complex of decisions on my part, some of which are determined by circumstances.
Yes actually.
To stay at one of those places, you have to take one of *these* bad boys these days, regardless of being considered a severe case or not.
https://en.wikipedia.org/wiki/Antipsychotic
The big problem with these, is that most long-term studies contradict them for the very disorder they are supposed to treat, IE severe mental health disorders. Patients who never take these at all, or only for week long outbreaks, do much much better then those who continually take them. I guess a simple analogy is that a person who drinks 6 cups of coffee to perk them up each day eventually becomes tired in a normal state. Problem is, some of the damage appears permanent and irreversible ( Tardive dyskinesia will make you a permanent ward of the state, and can be confused for the primary symptoms)
That’s an implementation detail, not a policy/philosophical argument.
If a facility is engaging in practices that create long term health issues, then that (of course) should be stopped.
Or you could figure that human nature being what it is, and the bell curve of human behavior being what it is, you’ll never eliminate that particular problem without causing a lot more and learn to live with it.
Poor homeless people make you feel bad and guilty about not helping them. But if there is no way to help them that won’t hurt many more people, perhaps you are best off changing your feelings to the world, not the other way round.
“Poor homeless people make you feel bad and guilty about not helping them.”
Yeah, that’s not the problem with street bums at all.
I don’t feel the slightest bit guilty about not helping them, but I do feel other things, such as:
– Annoyance at being accosted on the street
– Extreme annoyance at being disturbed on the subway[1]
– Discomfort and disgust at revolting body odor, especially in a confined space like a subway car
– Apprehension that the crazy-acting person will harm me or my friends/family[2]
If indeed the problem can’t be eliminated without causing more and worse, well, I suppose that’s life in the big city. But don’t claim that homelessness is only bad because of our guilty conscience, and that it has no actual effects on the rest of us; that’s just absurd.
[1] Panhandling in subway cars is illegal, but they still do it, and it’s infuriating when I’m just trying to relax / sleep / read — a sentiment obviously shared by most other passengers
[2] Not a trivial concern; see e.g. this very recent news story (not an isolated incident).
I suppose there is also a public health issue concerning the spread of infective diseases:
Homeless people spend literally all day in the most crowded places interacting with thousands people per day, they are often in poor general health, have extremely poor hygiene and they are less likely to seek medical assistance if they become sick. They are the perfect vehicle to spread anything that can be transmitted by breath, cough, sweat, urine or feces.
They will be the initial vector for the coming Zombie Apocalypse.
What’s the psychology – what does it feel like from the inside – of aggressively refusing to feel compassion? I see it sometimes but I’ve never experienced it so I don’t understand it.
Wild guess: It’s a defensive reflex. Either you’re afraid of being manipulated, that if you want to help the homeless you will easily swallow any bullshit that claims to help the homeless. Or you’re not afraid of being manipulated yourself, but you know “The homeless deserve human dignity!” and “Yay for compassion in general!” are war cries of a tribe that hates you. How far off am I?
After you accept Our Father Below into your heart, the only hard part is finding an unblemished goat.
“what does it feel like from the inside – of aggressively refusing to feel compassion?”
Oh, I feel compassion just fine. I just don’t feel a burning moral-imperative need to turn out my pockets in response. Mostly what I do is wonder why it was decided that these people would be better off this way.
@Leo:
This reads like being psychoanalyzed by a Martian. It’s not even insulting; it’s just bizarre. Not only does none of what you’re saying describe anything even in the general vicinity of my thoughts on the matter — even the phenomenon you’re (claiming to be) trying to explain sounds like some strange, alien misinterpretation.
“Aggressively refusing to feel compassion”? What? What does compassion have to do with anything? Are you… chiding me for lacking compassion toward homeless people? Suppose I do feel such a thing, what follows from this? Is guilt supposed to be a result of that? I guess I’m just confused about what your model of the world / human psychology / values / etc. must be.
What’s the psychology – what does it feel like from the inside – of aggressively refusing to feel compassion? I see it sometimes but I’ve never experienced it so I don’t understand it.
I wondered the exact same thing after reading that comment. But, maybe they refuse instinctively rather than aggressively? IDEK
To me refusing to feel compassion for panhandlers feels like avoiding a scam. It’s the mental reaction you get when you realize someone is not actually posting a real comment, but is posting spam.
Sometimes refusing to feel compassion feels like cleverness. “This politician has a sob story about Flint, but I know sob stories are a standard feature of politics, so I’m going to judge on the merits.”
Sometimes refusing to feel compassion is just a habit. I don’t refuse to find some things funny or cute, they’ve just gotten old. The fact some people are homeless amputees doesn’t arouse any surprise, interest, or compassion in me now. Although, I can’t remember if it ever did, or if I just saw them on TV before meeting them in real life and got used to them.
Let me just comment that Noumenon72’s experience does not match mine. (Not that Noumenon72 implied any such thing, nor meaning any offense. Just stating it for the record, since apparently some commenters are curious about some aspect of the psychology here — although I am still not quite sure what anyone finds confusing.)
It’s something that has to be actively taught to children with Williams syndrome, so they remember to stop and think “I don’t know this person, he may not mean me well.”
@Leo
My old paramedic instructor has a blog that might be illuminating. sadly I can’t seem to find the specific post I was thinking of about compassion being a finite resource, but these might give you an idea…
http://www.ambulancedriverfiles.com/2012/01/09/soul-callus/
http://www.ambulancedriverfiles.com/2007/09/23/a-tale-of-two-patients/
Said Achmiz – this is my feeling exactly. I live across the street from a public park, where homeless camp in the picnic shelter right next to the play equipment. I personally witness yelling and threats of violence WEEKLY from these trolls. The police tell us there is nothing they can do unless they can catch that specific individual in the act.
This is in inner PDX in a good neighborhood. I would gladly pay more in taxes for these guys to be institutionalized. “Community support” is a joke.
ETA: I lived downtown with this all around and didn’t GAF until I had a baby. I guess I was willing to be personally harassed/threatened but not my kid.
I was just about to comment that I had a lot more compassion before I moved to my current job and most walks to lunch result in getting panhandled. Sorry guys, I can’t help even a fraction of you without ending up on the street myself.
This is, of course, in downtown Portland.
You’re equivocating between fully eliminating a problem and taking steps to reduce or alleviate it. Obviously it’s possible to do one without the other.
Also, what do you mean by the bell curve of human behavior? The only way I see that a bell curve of human behaviour would mean homelessness cannot be reduced is that almost all homeless people are just natural and ireedeemable members of our untouchable caste, and so, properly and correctly there. (and also that compassionate alleviation type stuff is bad value in an absolute sense)
I have no proof that isn’t the case, but it’s a pretty big claim, so if that’s what you’re saying you should back it up with something. If you’re not maybe clarify because that seems to be the only argument that could do the work you’re having your reference to a bell curve of human behaviour do in the post. (implying that there’s no way to help them that won’t hurt many more people)
If that’s not what you meant, please take this post as a challenge to your phrasing/semantics, then.
Of possible relevance: the story of Million Dollar Murray and the power-law distribution of homelessness, here–http://gladwell.com/million-dollar-murray/
It sure seems like this program works pretty well to mitigate the costs of homelessness, both for the homeless and for the rest of us, modulo some concerns about moral hazard (and personal agency?). But it also seems compatible with an account in which all you can really do to help some people is warehouse them humanely, and the best you can hope for is that they’ll break their own windows instead of other people’s and sleep off their binges under a roof rather than on a sidewalk.
(Edit: and see also nil’s comment immediately below about Housing First. That’s what I get for not paying attention.).
Obviously it is possible to reduce homelessness. We have taken most of those steps. Hence, what we have left is very difficult to tackle, if not impossible.
How would a bell curve mean that homelessness can’t be reduced?
I’m just saying that at some point, you can’t reduce it without incarcerating people who are too out there to even be housed in completely free and provided care (holding for now the question of whether that option does more harm than good).
In the US today, there is absolutely no reason for anyone to be chronically homeless. This is a problem we have solved. There are tens of thousands of programs, shelters, government agencies, private charities and community groups whose sole existence is to reduce homelessness. This may be small comfort to those who don’t know about them, or can’t qualify yet, or are marginally housed, or really really want to live in a big nice city instead of some rural backwater, but it is reality. The only people who are chronically homeless either choose it as a sort of punk lifestyle, are too mentally ill, addicted or deficient to deal with the most welcoming of bureaucracies, or won’t go to where housing is available.
If it helps, I was homeless for about nine months, during which I lived out of my car or squatted in unoccupied buildings. I know something of the life, if only temporarily. I do sympathize with people who have a bad run of luck and wind up homeless, and helping them is effective and useful. But the chronically homeless? You won’t ever get rid of that problem.
Thanks, I wasn’t getting you at all. I thought you were implying that homelessness was essentially caused by the property of being unhelpable, rather than that some portion of homeless people are so pathological as to be impossible to ~”take back into the fold”, and that there’s already enough charity and aid in the US that people that the resources are available for people who aren’t like that to be helped to their feet.
About the bell curve. I didn’t see what the bell curve had to do with some people being unfit, for society, or otherwise unhelpable. -The bell curve refererence is closer to a decoration than a vital illustration, right? Well I had the impression the “bell curve” part of it was a central part of the argument, so I came up with a fairly complex misreading where it was. Tracking down exactly how that arose and laying it out would be fairly laborious, so I won’t.
re: last paragraph. In spherical-cow theory, that shouldn’t help, but I think in reality that it should. In this case no help was necessary as it was a case of misunderstanding that’s been cleared up, but I do think the idea that scotsmen are in a better position to to comment on scots fundamentally makes sense as a social principle. Normally I’d be inclined to argue the point (well, any point, really) now that I understand it, but instead I would just like to encourage you never to take seriously the idea that you weren’t a true scotsman in such a case as this, because scotsmanship, in almost any area where it can come into question, is a continuum, not a binary, and, especially if if scotsmen are rare or for some reason silent, then having been any kind of scotsman, whether it’s 9/10ths, or 3/4ters, or 1/10th, or even 1/100th, puts you in a better position to comment than an outsider commenting. Imo that is a sound principle of interpersonal communication under uncertainty, (aka 95%+ of interpersonal communication).
-it would help, if, rather than being uncomprehending, I was suspicious, or perhaps felt I was on very dangerous moral ground to be entertaining any ~”negative” description of someone in an emblematically bad position (like homelessness). And I think that generally it should help in such cases. Not always, but often.
“Just giving them housing” does seem to work. It’s called the Housing First model, and in a country with as much space and excess housing stock as the US, envy isn’t a good enough reason to not use it.
Especially if you do the smart and not-perfectly-liberal thing and at least drag your feet in implementing it in places with sky-high rental/real estate values. If they did Housing First in the rural town I live, or even the major midwestern city where I used to live, they wouldn’t have to explain anything to people “working two jobs to afford a shared studio apartment” because those people don’t exist here or there.
How do they decide which neighborhoods end up providing housing for (ex)homeless people?
This isn’t a rhetorical question: I’m not really sure how this decision gets made. It seems like a big deal too given the pushback to accepting Section 8 vouchers and housing projects.
Can’t tell from a brief scanning of the various articles, and I don’t have any special expertise. I agree that they must face some of the same challenges, but would note that a challenge is not an impermeable barrier–Section 8 gets pushback in some times and places, but it is still a more-or-less functioning program.
Plus, while the chronically homeless population is bigger than everyone wishes it were, it’s waaay smaller than the population served by Section 8.
I doubt that this would remain the case if being “homeless” got you free housing
Depends on the quality of the housing. Reading between the lines, it appears to be very basic and often in the same building as other formerly-homeless people. Qualifying as chronically homeless under the federal definition (page 4 here) requires living on the street or in a shelter and having a history of doing so. It could be gamed like any other social benefit, but I don’t see the risk thereof as being especially acute or extraordinary.
“How do they decide which neighborhoods end up providing housing for (ex)homeless people?”
Whichever neighborhood has the least number of votes gets the homeless shelter.
That’s how it normally works, yes, but if I understand it correctly this project isn’t about building shelters as such. The whole point is to put homeless folks into existing (presumably normal) residential buildings.
If the city buys up a few dozen foreclosed houses out in the suburbs and hands the keys over to their homeless population, what can the locals actually do about it other than move out? Hell, a private charity could probably implement that policy entirely on its own initiative. It seems like fighting it would be significantly harder than with existing programs.
“It’s hard to avoid the conclusion that many street bums need to be in custodial care of some kind, whether that is officially called a “mental institution” or not. ”
Like I said elsewhere; what most of the street people you see need isn’t money or a house; it’s an authority figure, a parent or a spouse or some other minder. Many of them would probably be quite happy in their lives if only they had someone to tell them what to do.
I’ve met the chronically hobo before.
They are not always alcoholics, though its easy to see the vicious cycle.
More then not, they seemed like older men with some combination of the traits of
1. Bottom fourth of intelligence, so colleges that are not outright scams like UNI of Phoenix are out. 2. Bad health problems, so manual or skilled labor is out. 3. Previous felony or misdemeanor, so basically none hires you. The third one alone can do it. The first two in conjunction seem difficult to get around, since you’re in the “gray zone”. Too messed up to work, not messed up enough to qualify for significant government aid.
Its difficult to dissociate mental health issues and alcoholism from the above issues. If you can’t afford a month rent barring three months of random jobs here and there, can’t get a steady job, but can afford a drink or a flask now and then, what do you spend it on?
ordinary people who fall on hard times can usually, if worst comes to worst, move in with family members or crash on a friend’s couch. That’s housing insecurity, and it can be brutal and humiliating, but it’s not “homelessness” in the sense most people use that term. To end up out on the street, someone either needs to alienate every member of their support network, or not have one to begin with. That usually takes seriously crazy behavior.
This assumes a lot of things.
Not everyone has a large circle of friends. There are high-functioning people who may just not be very social, and their parents/other relatives may no longer be alive or may not be on good terms with them (and that doesn’t necessarily take “seriously crazy behavior,” it could be ideological disagreements or personality clashes or any number of other things). And even if they do have relatives or friends who are willing to let them crash for awhile, people’s patience is not infinite. If you’re totally destitute, it will take awhile, probably months, to get back on your feet. And most people are not going to be willing to let you crash on their couch indefinitely.
Are there any good statistics on the ratio of mentally ill to mentally “healthy” in America over period of time that people know of, and have on hand? Has it changed at all?
From what I’ve seen, a massive climb in the rate as we classify more and more things as “mentally ill”. The classifications get very, very stupid. You might have a few percent with serious things like full psychotic breaks, uncontrollable bipolar, etc. Maybe five or ten percent with clinical depression. The rest are all perfectly normal people who had a bad life event and reacted completely normally, but then we medicalize it. Things like temporary depression (say, after a parent’s death) or PTSD are NORMAL reactions to bad situations. And then, of course, you have the outright fraud (multiple personality) and the special snowflake jockeying (ADHD and autism spectrum*).
*which are real, but parents are incentivized to get their kid diagnosed with something like this both for social and financial reasons. Hence the numbers of diagnoses are massively inflated.
Just because we classify more things as a mental health issue than we did in the past, doesn’t mean we are wrong now. In fact it seems far more likely that we were wrong in the past.
The mere fact that PTSD is a perfectly normal reaction to a bad situation, doesn’t mean it shouldn’t be treated. A fever is a perfectly normal response to getting the flu, but that doesn’t mean someone running a fever is perfectly healthy.
Many of the things we classify as mental health issues are pretty minor. But there’s nothing wrong with that. They are still issues, and fixing them will improve people’s life. Just like many medical issues are pretty minor, but we still try to fix them.
And I don’t think there’s anyone on earth who wouldn’t benefit from an occasional talk with a good psychologist.
Sorry, this isn’t really a response that fits into the thread, but I think that last statement there is pretty misleading:
To start with there must be at least millions of people who’s embarrassment at the situation would outweigh any possible good that could be done. Even if you somehow could psychically guarantee that this psychiatrist would be good, vis a vis them, loads of people have way too strong personal injunctions or hangups or whatever you want to call it or whatever the variety is, for the psychiatrist to even be able to do any good at all, let alone to outweigh the stress of a person going heavily against their mindstate/set, or current nature -I don’t think current nature is too grand a term because for some people “I will handle things myself” or “I will never entrust another with my psychological wellbeing” is a fundamental part of their self conception, and for others who have been burned by psychiatrists, or heard stories, something as specific as “I will never go to a psychiatrist as long as I live. (not going back there/not falling for that nonsense/scam/touchey feeley crap)” might have the same pride of place.
And isn’t the main problem finding a good psychologist anyway?
Then there are surely people who have a good understanding of themselves and framework such that interaction with a foreign perspective, with all its particularities and fashions, intertwined with the good it can do, can only serve to confuse them. Even if we assume that modern psychology practice is methodologically perfect, most psychologists, being accredited practitioners of a particular craft with a certain philosophy (official “ethics”, at a minimum, but it doesn’t start or stop there), are going to tend to be rigid and dogmatic about certain things, which could either stress someone, or lead them astray (badly). And equally if someone has such a framework and understanding of themselves, but it happens to be highly idiosyncratic, then even a very open minded and brilliant psychiatrist might not be able to do anything for them but confuse things.
Or if that doesn’t apply, it might be true relative to an honest, earnest and unafraid friend, which is imo basically most of what you’re paying a psychologist to be, though perhaps the friend, in that case, counts as a psychologist. There is some unique value in the fact that a psychologist is a stranger, initially to you, and then to other people in your life, plus their professional bindings (confidentiality), which a friend might have, but be less able to prove, but then again might be more able to if you’ve known them longer, but anyway I think relative to, say- nothing, a friend, or a forum, the advantages of a psychologist, even one magically guaranteed to be good -for you (but you still have no way of knowing that), are far from universally decisive.
And also, stipulating, “a good psychologist” makes it pretty circular in my mind. I don’t think there’s any such thing as a universally good psychologist, so a psychologists quality classification, while it has a generally general component, is ultimately relative to the client, at least as far as the client is concerned. So a good psychologist, is one which works for you, in which case, yeah, minus above caveats, of course anyone would benefit from a talk with a good psychologist, that might have to literally be Jesus Christ, as advised by buddha, in some cases, that might not even do it, but double BuddhaJesus might, so the conditions still hold for that case, even if there is no doubleBuddhaJesus, or even no single Jesus, because if there was, then the person would benefit. And anyone else isn’t a good psychologist relative to them.
And I don’t think there’s anyone on earth who wouldn’t benefit from an occasional talk with a good psychologist.
I think a lot of my resistance to counselling comes from my feeling that okay, so I talk about my life and we trace things back to when I was a child.
Well, then what? Something happened thirty or forty years ago, it’s over, it’s in the past, it can’t be changed. The people involved are dead or long gone elsewhere. About all you can do is say “Yeah, that wasn’t great” and get on with life now. All a counsellor can do is say what boils down to “Don’t think about it any more”, sympathise a bit with me, and that’s it.
I can look up the coping tricks on the Internet (though CBT was useless for me, and that’s as much me as it), so why go to a counsellor/therapist? Talking about “my sad life when I was twelve” feels like stripping off naked in front of them and about as embarrassing, humiliating, and ultimately useless as doing that would be.
Word. I posted a lot about this in the “Two Attitudes” post comment thread — I have a hard time imagining what I could be told that I haven’t already thought of. (Funnily enough, “just don’t think about if” seems to be what I’ve arrived at, too… Great minds think alike, right? Rosaries, Buddhist or Catholic, and breath meditation are also good.)
If I understand correctly, clinical PTSD, that is, impaired functioning for more than a month after the traumatic event, is relatively uncommon.
It is, but only to the degree that the situations that produce it are uncommon. WW3 breaks out, we’re gonna have a real issue with PTSD. As it is, not so much. Although college kids seem to be working pretty hard to give themselves trauma over such horrifying circumstances as being disagreed with.
PTSD is uncommon even in legitimate trauma victims, SJWs notwithstanding.
vV_Vv
Do you have numbers for how common PTSD is for people who’ve experienced significant trauma?
According to Wikipedia: “The National Comorbidity Survey Replication has estimated that the lifetime prevalence of PTSD among adult Americans is 6.8%, with women (9.7%) more than twice as likely as men[60] (3.6%) to have PTSD at some point in their lives.[153] More than 60% of men and more than 60% of women experience at least one traumatic event in their life. The most frequently reported traumatic events by men are rape, combat, and childhood neglect or physical abuse. Women most frequently report instances of rape, sexual molestation, physical attack, being threatened with a weapon and childhood physical abuse.[60] 88% of men and 79% of women with lifetime PTSD have at least one comorbid psychiatric disorder. Major depressive disorder, 48% of men and 49% of women, and lifetime alcohol abuse or dependence, 51.9% of men and 27.9% of women, are the most common comorbid disorders.[154]”
@ Nancy Lebovitz,
Can’t speak for any other circumstances but the conventional wisdom when I was still in the military was that ~15% of active combatants would require some sort intervention (medication, counseling, etc…) for PTSD and those numbers seem to square with personal experience. Note that this ignores some of the more benign manifestations like sleeping with your boots on.
Substance abuse and other self destructive behavior seemed to be a separate, but possibly related issue.
So apparently, after WW2 and Korea, American soldiers went home on long ship rides, where they were in a controlled, but fairly safe environment, and if they had worse-than-usual symptoms, the docs or chaplains or other counselors could work with them. During Vietnam (and after), we fly our soldiers out of combat zones and drop them back into society after a much shorter period, around way fewer people that have shared experiences during the transition. This may have something to do with why there seem to be so many more long-term problems with Vietnam veterans than with the previous generation of veterans. We seem to have fixed things somewhat since the First Gulf War.
If “medicalizing” a bad spell in someone’s life helps them recover more quickly, I think that’s a good enough reason to keep exploring the option. I seem to recall that SSRIs have been able to treat depression-due-to-grieving, as well as clinical depression, for instance.
(I apologize if the quotes made this comment come off as hostile, that’s not the intention)
If.
+
It’s also very hard to explore that question without confounding effects, because the mentioned habit of classification is part of the current culture, in which the question of whether people are better off or not depending on whether their problems are deemed official, has to be settled.
For example, if you have a body which assumes the authority in a society to rule on whether a problem is worthy or not, -“is a thing” or not, then having a problem which is not deemed medical is different from having the same problem in a society where there isn’t a hard divide manufactured along that line. Or e.g. one opposite correlate of that is that in a society where medical classification is an official sacrement (even if it’s perfectly accurate in all cases), someone having their problem recognised can give them permission to not pretend their problem doesn’t exist and they are making it up. The kid who’s just bad at spelling, or just slow, is in some sense worse off in a society which acknowledges/classifies “learning difficulties”, because he’s been looked at, and it’s been decided that he has no excuse (only officially, and technically, but is that what comes across, if no measures are taken?) Obviously this kid has a learning difficulty, he’s fucking slow, (like plenty of people who have achieved great things), but now the elders and druids in their robes and authority have passed over him in judgement, speaking for society, setting the consensus reality, and decided the other kid with really bad grades has a learning difficulty, but this kid doesn’t.
Imo psychology ruling and setting schelling points on marginal and edge cases is a practice that’s destructive to the zeitgeist, and the piper’s going to have to be paid. (and already is, but the long term damage of the falseness involved and misleading of people will be subtle and diffuse.)
(not saying that there was any other way to move forward btw, maybe this is the best that can be done. Sounds pretty plausible, if you can’t convince people not to be cunts in general, you can at least label a bunch of specific things as official-things-not-to-be-a-cunt-about-or-you’re-so-last-week. Obviously even this hasn’t gone perfectly but maybe this confusion and/or deception was the best thing available. There’s also the principle that it’s possible for it to be better to have an imperfect/bad label than no label)
(I am talking about edge cases here, so something like “crippling depression and anhedonia” doesn’t fall under a lot of what I’m saying, while cluster symptom “disorders” like dysgraphia or schizoidism, where there is no known mechanism, proposed mechanism, or even the idea that there needs to be any kind of mechanism, or natural clustering of symptom criteria, for the cluster to be an official medical ratified diagnosis, and it’s fine if they’re basically just free floating brands that people use like the MBTI or astrology, and maybe the misleading official ontology is even a feature. -do fall under what I’m saying, though again, maybe that is perfectly fine, or even totally harmless (as in it both does good and does no harm), or even philosophically and societal innocuous, -I’m genuinely agnostic on that historical and current question, but I am sure there are better ways to do these things, or if I’m wrong on that, which from my POV is just about possible, at least purer ways).
If dealing with life’s ups and downs makes one stronger and more resilient then I think that we *shouldn’t* medicalize away every problem.
Isn’t possible to deal with them using the tools that medical science yields?
Is it likely that popping a pill for each problem you have will make you stronger and more resilient?
Maybe… Are you talking about metandienone? Propranolol? Anadrol?
And pills aren’t the only tools that science yields.
Yes, but the problem with that is if depression-due-to-grieving is seen not as normal, but as “it’s been a whole six weeks and you haven’t moved on yet? get some medication so you act peppy and cheerful again!”
People used to be given time to grieve (even a whole year in mourning for a close relative). That may have morphed into social obligation and held people back when they were recovered, but the opposite impulse – to treat the Kubler-Ross stages as a timetable to be gone through in strict rotation and “it’s week eight, now you should be at acceptance and moving on” – is equally or even more damaging.
How real is ADHD?
I’ve had actual doctors say that since I performed well in school, there’s no way I could have that disorder.
Some doctors believe that the disorder somehow “goes away” with age, aka “You’re no longer a rambunctious young boy and you now understand school is important, we can stop throwing meds at you to sit down and shut up”
Why do so many normal students take Adderall and show improvement with anecdotes? Its really just seems like caffeine to the third power.
The one kid I did know with an ADHD diagnosis (the son of a co-worker who coincidentally attended the school where I worked) definitely had a problem; it wasn’t just restlessness or daydreaming or “normal boy behaviour”.
He had the involuntary tics, muscle spasms, vocalisations, problems with focus, lack of co-ordination, etc. He did feel embarrassed and felt he was ‘standing out’ at school because of making loud noises and exclamations in class without meaning to, etc. So medication and treatment were genuinely necessary there.
Ireland hasn’t yet gone down the American route of diagnosing everyone with ADHD and prescribing strong drugs to young children, though we’re getting there. I remain fascinated (and a tiny bit appalled) by all the Adderall anecdotes I see on here and elsewhere. I don’t know what college life in Ireland is like, but I’d be very surprised if even now it was routine, or even common, to say “Yeah, I went to my parents’ GP, told them I had trouble concentrating in class, and they wrote me a prescription no bother”.
I have to say that sounds more like Tourette’s. Have they ever been related?
>So medication and treatment were genuinely necessary there.
Perhaps, if there end up methods of counting calories that are adhered too. A good spat of evidence says that these stims stunt growth in children. I mean, adults use them as appetite suppressants to lose weight with good effect. Some kid who simply isn’t hungry isn’t going to report much.
I’m worried about an effect commonly observed, such as the medications used to treat a disorder, end up making it much worse over time. Long term antidepressants being linked to adhenia after yeasr of usage. Long term caffeine to chronic fatigue. Long term antipsychotics to…chronic psychosis.
No, amphetamine is not just strong caffeine. Here is a simple test: compare the response to modafinil and the response to amphetamine. Ideally, compare executive function; practically, compare subjective (but retrospective!) productivity or performance on schoolwork.
If someone is a candidate for ADHD, this is probably a reasonable criterion. If he is not a candidate for ADHD, then there are probably lots of other reasons for failing to respond to either drug.
If you believe this, it should convince you that ADHD is a “real thing.” But that’s probably not your real question. Whether either people with ADHD or normal people should take drugs is a difficult question. But they definitely should take different drugs.
I don’t quite think so.
There’s so many cases of people in UNI, both top and non-top, giving “amazing” anecdotes of how Adderall helps put you in the zone. Athletes to. It probably effects people on a bell curve distribution, like usual.
I guess it makes sense. That one hobo mathematician last century took another form of amphetamines and reported good reports.
But I am absolutely opposed to the lovely ADHD med trend in America. It seems to be dying down, though. In france and Germany, there is a large distrust of those meds, and the schoolchildren in alternative methods tend to do around as well on average academically. It really just seems like a chemical method to control behavior in the classroom rather then a learning aid, at least at the young age.
A blogger I used to read made some comment about the 50 browser tabs and 20 other things open on his desktop. He was a web and database developer. He pointed out it’s only a disorder if it interferes with your relationships or earning a living.
Emergency dispatchers (and even non-emergency ones) seem to find ways to profit from that tendency.
Re: the war on drugs, the upward trend on that graph starts right after the creation of the DEA.
It takes some willful ignorance of the past forty years to interpret that graph in the way Lopez wants us to interpret it.
Agreed. Apparently in the 70s people who study criminal justice were predicting the end of prisons in America. But then whoops, drug war.
I was under the impression that Nixon intended the DEA to be a largely treatment focused organization that was headed by a doctor who ran a methadone clinic. The program was relatively successful but unpopular, leading to the current war on drugs.
Re the underavailability of psychiatrists, my girlfriend and I recently found that there basically aren’t any psychiatrists in LA who both do (any kind of) talk therapy and take insurance. Is this pretty much a hopeless nexus of insurance companies incentivized to incentivize medication management practice and psychiatrists incentivized not to deal with their crap, or is there hope for improving the situation before the Millenial advent of socialized health care?
Come to think, do Canadian psychiatrists in private practice tend not to take the government’s money? Surely in a fully socialized system they’re generally government employees and can’t avoid taking “insurance-” is psychiatry also decaying into medication management in the UK etc?
There is no private option in Canada. Psychiatrists may run private practices, but they bill Medicare, not individual patients. As a doctor, your only option is to take government money.
You can get talking therapies on the NHS although it varies by region. In London I was offered CBT or CAT through the Community Mental Health Team (they work with patients who have had a psychiatric referral from a GP) and if you aren’t in need of a psychiatrist your GP can refer you to the counseling route which offers more variety I believe.
Long waiting times – 4-6 months I believe – but there.
An honest question: what is the value in using a psychiatrist as a therapist?
I helped a badly-depressed friend of mine find a doctor to write him a prescription for anti-depression medication. As I researched it, it looked like this was essentially the primary/sole function of the vast majority of psychiatrists in my area. It looked like their strategy was to minimize patient contact while still trying to periodically get some juice for renewing the prescription. I called a few and pointed him to one of the cheaper ones, which I think was still in excess of $100/hr. I’m not sure if there was a better way to do this.
During a rough time in my life, I saw a therapist recommended by a friend. He was very good, had a master’s in something therapy-related from a middling public school, and charged maybe $70/hr. I don’t think med school plus residency would have made him any better at his job, unless perhaps I had a mental illness. But it probably would have given him justification to charge a significantly higher rate.
My personal experience with psychiatrists is that they are there to rubber-stamp the psych meds I want/need. I have frequently left their office thinking “if I’m the one with the social anxiety, how come I feel like a Toastmaster compared to these guys?” I can’t imagine trying talk therapy with any of them.
(Our host is training to be a psychiatrist, right? I hope Scott isn’t offended by this.)
Psychologists and counselors do talk therapy. Counselors are easily available but don’t take insurance. (My church has a counselor who is fully educated the way you would want a counselor to be, and if you don’t feel like you can pay that’s fine. Even if you are a non-believer.) Psychologists are covered by insurance but take a while to find.
Psych drugs are not really just one-and-done. How they are helpful or unhelpful changes a little according to how your life changes. I find that not really being able to talk about drugs I take with my counselor is really frustrating. She’ll listen, but try not to advise anything other than “Talk to your doctor.”
Thanks, Magnetick. I guess you have the answer — at the intersection between life and drugs is where a conversation with a good psychiatrist can be helpful. But Edward’s experience seems to align with my one foray into dealing with psychiatrists.
As in Edward’s case, the therapist I talked with was associated with a church. While I’m not exactly a nonbeliever, I was definitely not associated with that church, but his approach was only as religion-infused as I wanted it to be.
He was also prepared to drop his rates to effectively $0 if needed.
The purpose of talk-therapy is to encourage women to abandon their husbands or boyfriends.
Could you elaborate?
Sadly, I doubt this comment has any subtext. It means what it says.
The notion of going to a therapist (psychologist) when unhappy gained acceptance in the upper middle, then middle classes from the late 1920s through the 1970s. By the 1980s and 90s even the lower classes had some sort of access to it.
During the late 1960s, 70s and 80s there was, at least in the pop-psych books, the notion that it was better for people to divorce if they were “unhappy”, and that children were better off parents who were unhappy together got divorced. There are still people who buy into both notions.
It was also during that period of time when no-fault divorce laws came into being.
Track divorce rates over those times. Track the number of people visiting therapists over that time.
And keep in mind that the decline in pirates has lead to global warming (and the increase in pirates off the somali coast is what caused the global warming hiatus. 🙂 )
Thus there are a number of men who believe that their ex-wife/girlfriend’s therapist “encouraged them to leave me”. This actually *might* be true in many cases, and in at least some of those cases it would have been unjustified.
But the male ego (which isn’t really *all* that different from the female ego in this sort of thing) will look for any excuse to blame someone else, and it’s a really short step in from “her therapist convinced her to leave me” to “the whole point of talk therapy is to…”, especially if you’re sitting sucking back bud light. And the stories we tell ourselves become the truth.
It is almost undeniable that *some* women were convinced to leave a relatively normal relationship (one with ups and downs, one where one or both of the parties wasn’t’ feelin’ it right now). The question that can’t be answered is what rate this happened, and whether the therapists in question had a bias against working through relationship problems.
I doubt seriously that talk-therapy was *intended* to encourage women to abandon their husbands. I seriously believe that it contributed to the increase in divorce rates in the late 1960s through the end of the 1970s.
There has always been a bias in certain circles
Oops, forgot to hit post!
Really?
Ms Brewer, people -smart people – absolutely believe these kinds of things. And they only get more committed to these beliefs when we express our shock.
Therefore, Political Correctness is the New Fascism, yadda yadda yadda. Pay no attention to the man behind the curtain. He’d only say “n*gger,” and giggle.
I suspect you are right and I would be wiser to not engage. Although if this were true, it would make life very confusing for therapists with straight male or queer female.clients. Maybe they just serve them cake?
(I have never had a therapist who encouraged me to leave my partner.)
I think the problem there is “insurance”. Insurance is based on “you pay a premium to cover exceptional events that are not expected or foreseeable”. Health insurance sort of falls between two stools because while you may never realistically expect your house to burn down, you do expect to get sick sometime. The money that goes to pay for treatments comes from the premiums people pay, and the idea is that younger/healthy people will pay in without claiming over a long period so that generates the pool of cash that the people who then claim on their policies draw upon. It depends on juggling revenue in and revenue out so that they’re always taking more in (from the non-claiming, premium-paying policyholders) than paying out (for the claiming), and one way to do this is cutting down on what they pay out (that’s why they won’t give you coverage if you have a pre-existing condition – at least, that’s how private health insurance in Ireland works).
Talk therapy is long-term, ongoing, and doesn’t have a neat “we do twelve sessions and you’re cured” end-date. That means it’s a horrible charge for insurance and if they provide it, they have to pay a lot of money out on your policy, which means in order to recover it they need to shove up your premiums, which means people screaming in outrage about the expense/dropping coverage because they can’t afford the plans, and probably laws limiting how much they can charge.
So a course of “we’ll pay a fixed amount per year for medication” is a lot easier and more attractive for everyone.
“and the idea is that younger/healthy people will pay in without claiming over a long period so that generates the pool of cash that the people who then claim on their policies draw upon. ”
That is not the idea, at least in a private insurance market. If it were, an insurance company could make a fortune by only insuring younger, healthy people.
The reason that doesn’t work is that, in a competitive market, the younger, healthier people pay lower premiums—premiums reflecting the fact that they are younger, healthier, and so less expensive to insure.
The idea is that the lucky people—the ones who end up with low medical bills but, unlike the young, cannot be predicted to do so—generate the revenue that pays for the unlucky people.
Exactly.
If we had perfect information, there would be no need for insurance, as everyone would pay the exact amount that his own healthcare costs.
It’s not a matter of paying in while you’re young to cash out when you’re old. That’s totally different.
Insurance can’t reduce the average cost of healthcare; it can only increase the cost, trading that off against decreased uncertainty. You should never have a positive expected return on insurance. If you do, that’s moral hazard.
This sort of thing is the root of opposition to things like genetic tests for health insurance. What such things do is increase overall efficiency and reduce premiums for the majority of people who do not have the disorders, while greatly increasing premiums for those who do have them.
I read that the reason psychiatrists have moved away from talk therapy is, in fact, the fact of their under-availability: they need to see so many people that they no longer have the time for it, and so — being the only ones who can prescribe — have kind of unofficially split the labor with various therapists and counselors to concentrate on that.
As someone else mentioned, suspecting or knowing you need some kind of medication is a good reason to go; but no need for the MD if not — it’s probably better to see a therapist for talkin’. I’m kind of skeptical that talk therapy can ever be useful for the introspective, though.
I don’t believe insurance companies directly incentivize psychiatrists to avoid CBT or the like. I may be wrong, though… Scott?
Vox is such an atrocious news site. I really dont understand why you continue to give them your page views and attention.
They’re trying to have a reputation as an intelligent and reasonable website that explains the news, which makes it more important to point out how wrong they are.
Or if not more important, more fun.
Vox is very close to what a lot of SSC readers would like a news website to be, so when it fails it’s really disappointing and frustrating. Scott generally doesn’t correct articles on TheBlaze or HuffPost, because we all assume they’re terrible. Vox at least is close to being good, and when it’s bad that makes it worse.
Also I like their podcast.
Vox’s original premise had so much promise – bring the sort of detailed policy reporting Ezra Klein did for the WaPo on health care reform to every story. But it turns out that doesn’t get shared or liked or tweeted, so instead they became Gawker Lite. (Thankfully they haven’t dropped to Gawker’s level of moral bankruptcy…yet.)
There’s a lot of wasted promise, sure. But it’s still way better than most other media. Compare the last dozen stories on Vox and the last dozen stories on CNN.
I don’t want to argue Vox is great, but it’s better than the others. Which admittedly is a low bar.
Also: their podcast is fun to listen to.
They haven’t dropped to Gawker’s level because they still have a growing market for them. Once the chips are down, they will start to produce more well-intentioned but fact-distorting quasi-clickbaity articles like this. Progressive websites can start to degenerate as quickly as the seasonal political conditions vis-a-vis markets that support them start to change. The lack of consistency in quality and the pressure to produce more relevant content about the latest polemics are evidence that quality will go down.
It might be more accurate to say that they became Gawker Heavy, with roughly the same focus on how any given policy makes you feel but with an added empiricist veneer.
That’s not what Gawker is trying to do, though. Best I can tell, Gawker started out as a celebrity gossip blog that gradually expanded into a news empire with the same nihilistic paparazzi attitude.
The whole point of Gawker is the snark and sleaze. If Vox is a much less sleazy, slightly less snarky Gawker, it’s Gawker Lite. Or maybe the Chipotle to Gawker’s Taco Bell?
Pardon my imprecision. I was referring to Gawker Media writ large and their overall strategy of applying snark and ingroup signalling to whatever the particular topic of one of their sites or individual posts.
Vox does not rely on snark, but they do an awful lot of mood affiliation and ingroup signalling where some very shallow empirical work is serving the same function that snark does on Gawker Media sites. That said, they do, on occasion, do some good journalism. There was recently a very good explanatory piece on the foreign policy trajectory that led to the invasion of Iraq.
They have the trappings of the sort of heavy, in-depth analysis this blog’s audience craves but without the rigor to back it up.
Too bad Ezra Klein doesn’t scale.
I can see, reading various Vox articles, how other workers at Vox have tried to cargo-cult being like Klein. They use numbers and sophisticated arguments, but they can’t really get Klein’s willingness to slaughter progressive sacred cows when necessary.
Klein is probably the best pundit on the left about health care policy, but most people on the left are completely unaware of his writing.
I don’t know much about Ezra Klein and I’ve read little of what he writes, but what I have read impresses me.
He seems to be a genuine old-fashioned journalist, one that follows the facts and writes the story around them. He doesn’t slant, he doesn’t start off with a ‘narrative’ and arrange things to support it, he may have an idea of how he wants the story to go but if the details don’t back that up, he says so.
What passes for modern journalism, especially in the dog-eat-dog competition for online traffic, is a horse of a different colour.
They have huge political biases, although I guess those are obvious enough that if you are at all observant you can correct for them.
Whenever I know a topic well that Vox is writing about I see significant problems with their assertions. That is true of many media sources of course, but their tone of smug self-assurance doesn’t help. There is a lot of questionable interpretation presented as self-evident fact.
“Whenever I know a topic well that Vox is writing about I see significant problems with their assertions. That is true of many media sources of course, but their tone of smug self-assurance doesn’t help. There is a lot of questionable interpretation presented as self-evident fact.”
Also, while I appreciate very much the thought process that led to them not hosting comments sections, it really accentuates this problem.
I used to cheer along whenever I saw Scott refuting Vox, but this comment made me wonder if the Vox folks wish they could cite the Copenhagen Interpretation of Ethics every time he writes a takedown like this. (“We’re trying to do better than other news sources at being fact-based & nonpartisan, and we’re kinda actually succeeding a little bit! But we still have to make a profit, which means pumping out a lot of articles… Then along comes this Scott Alexander guy who decides it’s his life mission to point out all the mistakes we make while largely ignoring the mistakes made by other news sources. It’s impossible to win!”)
I feel like Scott’s criticism of them is mostly “friendly”.
He’s mentioned that he doesn’t critique a lot of conservative-leaning news sources because he doesn’t find them worth reading at all.
I certainly don’t agree with Vox’s editorial line, and I take issue with some of their articles, but I still regard them as a pretty good news source, especially if my goal is to find out what the informed left-wing position on some issue is.
Has Vox produced anything truly excellent that is agreed to be fact-based and nonparitsan? Weaker question: have they published any piece of bona fide impactful journalism?
I ask this as someone who used to read Klein, Yglesias, and Matthews before they did Vox, and reads almost none of their work now.
I’m curious about how the problems the US has with it’s mental health care system, mostly that it can be difficult and expensive to access treatment, compares to countries with centralized medicine, like the UK.
Yes, or Singapore.
I had to wait four months to see a therapist. Four months. Once I saw the therapist, the therapist essentially ignored everything I said, gave me no actionable advice, and just asked me about the mundanities of everyday life. The video games I was playing. What I was learning in college. If I did anything on the weekend.
Want another doctor? Too fucking bad. If you’re lucky, you can wait another 4 months to see a different guy. That’s if there are any different guys available.
When I lived in the states, therapy cost $150/hr and was rarely if ever covered by my insurance. But at least I could go see someone _tomorrow_ if I needed to
Surely Canada has private therapists if you’re willing to pay?
Some of the provinces ban private health insurance for anything covered by the state health care system (and under federal law private clinics generally can’t charge patients directly), so for some services there really might not be a private option. A few years ago the Canadian Supreme Court ruled that such bans could be illegal if wait times were long enough, but I don’t think anything came of that decision.
Wow, that’s bizarre. How did the government get away with nationalizing an entire profession?
The UK has a massive issue with people getting access to good treatment for MH issues. One friend of mine was kept in a bed in the emergency ward attached.to A&E for two days because they couldn’t find her a bed in a psych ward anywhere in the country. I spent four months on a waiting list for a psychiatrist and only got access after I was admitted into a psych ward as an.emergency admission with psychotic symptoms.
The good news is that at least my hospital stay didn’t bankrupt me though which I’m very grateful for and I now am pretty stable with meds and treatment not costing me anything. This is good. But we do have an issue with people getting prompt and appropriate access.
It has generally seemed to me that healthcare is a finite resource, and so must be rationed one way or t’other. You can do it via money, as in the US, or via time, as in the UK, but either way it seems like access is going to be limited for some folks.
I don’t see how you come to that conclusion. The resources that go into producing healthcare can be used for all number of other purposes. People who become doctors could easily have entered other professions; likewise it would be possible for vastly more people to become doctors than currently do. Instead of medical machines, other machines could be made instead. Drug companies could produce more cosmetics and cleaning products and pesticides rather than medicine.
I’ve seen this argument made by a number of people, including our host – along the lines that healthcare waiting lists and death panels and so on are not a problem, because healthcare has to be rationed somehow. Of course it does. The sensible complaint about these things isn’t that healthcare is infinitely valuable and therefore anything that serves to limit it is bad – of course it isn’t. It’s that producing healthcare through government, similar to producing other things through government, means it will cost more, be lower quality, and there will be the wrong quantity produced, due to all the usual incentive and information problems affecting government actors.
Compare with the claim that there was nothing wrong with bread lines in the USSR, because obviously bread has to be rationed somehow.
There are some reasonable arguments for nationalized healthcare, but this is not one of them.
It isn’t a bad argument for nationalized healthcare, though – it’s a rebuttal of a bad argument against nationalized healthcare. The objection that nationalized healthcare involves rationing (and private healthcare does not) is a common one, so it seems perfectly reasonable to point out that it makes no sense.
(The more sensible argument that it will be less efficient and therefore involve more rationing also seems questionable, given how expensive the US healthcare system reportedly is.)
Also, short of forcing people to take up medicine at gunpoint, I’m not sure that we could increase the output of doctors all that much. What would you suggest?
“Also, short of forcing people to take up medicine at gunpoint, I’m not sure that we could increase the output of doctors all that much. What would you suggest?”
To Harry, I would suggest
(i) Reconsideration of credential requirements of doctors, and
(ii) Reconsideration of institutional disincentives to potential doctors.
[With “doctors” being a placeholder for “providers of medical advice and care” in a broad sense that would include psychologists, coaches, nurse practioners, and perhaps many other things we might be able to imagine.]
I think most people would agree that the way institutionalisation fossilised was a real problem, and that supporting people at home was a better way.
The problem with “care in the community” is (a) it leans very heavily on family taking up the slack, and if families either cannot or do not want to take on practically full-time care for a relative, that leaves people isolated (b) funding and resources in the community need to be there; there’s not much good in plans based on “and there will be respite care for care-givers and regular visits by health workers and a care plan drawn up and put in place etc.” if the money isn’t there in the local authority budget to cover such things.
I assume the “about” has migrated four words to the left.
It happens.
More proof of the leftward march of the blogosphere. Wake up sheeple!
Nah — four words shifted one word to the right.
I do have to admit that this comment thread is drifting rightward. Trump 2016, he’ll make SSC great again!
SMOD 2016. Solve all our problems.
I think this is the best top comment chain I’ve ever seen on this blog.
If it were in the southern hemisphere, they would have migrated four words to the right. Only on the equator … .
Can anybody else control your writing? /s