What we should do about the mentally ill homeless

IMO the long acting drugs + more intensive caseworker intervention is the most feasible way for the very difficult to work with individuals. (Long acting is good for opioids as well, https://healthandjusticejournal.biomedcentral.com/articles/1...).

So there is a mixture of types of homeless -- some of the examples Scott gets into for "draconian" are for what I would call transient/short-term -- those folks some welfare type intervention (housing vouchers, cash) to smooth over their instability is all they need. Those are not the homeless people are complaining about!

The "pollution" homeless though Scott is mostly talking about are the people who cause public disorder. And those are very hard to deal with. So everything will be difficult, but I think caseworkers being able to help them as much as possible is IMO the best approach I've seen work in some cases.

It sounds like one potential problem is with all the hurdles around acquiring anti-psychotic meds. Is this something we could loosen up on? As in subsiding the cost completely (i.e. $0 out-of-pocket). And not being very strict on prescriptions? Like the pharmacy could give out a second batch without question, if the first batch was "lost". Or maybe it is something that is almost OTC, but behind the counter like Sudafed? With the goal to make it almost as easy to get actual meds as it is to get fentanyl?

The housing first program shows that it is way easier to treat the causes of chronic homelessness if you put people in housing. The total cost when counting ER visits and police intervention is 4x less under housing first. The evidence is clear. Believe it or don’t, but reality is the thing that exists even if you don’t believe in it.

We should differentiate between truly low functioning schizophrenics that are in active psychosis and people who developed psychotic features through years of drug abuse. One is born that way or organically develops the condition, the other makes hundreds of small decisions that lead to destructive consequences that society is left to confront. Both are worthy of compassion. But, the latter has responsibility for their own choices. They should be held to a higher standard of expectations, including managing their own medical path and showing up to appointments.

One thing this article avoids, and most other advocacy articles do also, is acknowledgement of the vast numbers of mentally ill people who do prioritise their own care and participate in a structured treatment. It's disrespectful and ableist to group the worst behaviours of people that abandon their own care for street drugs, with the condition itself. Those people need to be held responsible for those decisions.

Consequences for destructive behaviour are crucial for a functioning society. Even many low functioning people understand consequences. What we have done is slowly remove the consequences for multiple tiers of progressively worse behaviour.

I have seen many freakouts and assaults in large cities and have also seen them act right up to the threshold of a consequence. Then when police show up, suddenly they know exactly what to say to get out of it. That is not someone who doesn't understand what is happening.

Involuntary hospitalisation needs to remain a tool, even as a last resort, to prevent escalation of conditions and for the safety of the general public.

Simply answer how would you want to be cared for if you were ill?

1) A comfortable bed

2) Engaging entertainment/task (eg folding laundry is helpful for some disorders)

3) Safe from abuse

4) Basic medical care

5) Place to sit for sunshine

6) Opportunity to hold hands / human touch

I'd recommend starting with https://www.astralcodexten.com/p/book-review-san-fransicko before reading this.

A very long title, didn't fit the limit, sorry.

This is a good example of a really hard problem.

> (Also, even in the best case where you successfully treat somebody, I’m afraid that “1995 - 2024: psychotic homeless person” doesn’t look good on a resume, so they probably won’t be getting high-powered jobs. Meanwhile, cheap apartments in SF are $1000/month. So the connection between “no longer psychotic” and “no longer homeless on the street” is tenuous unless you also have some plan to provide free housing.)

I mean, there is so much overlooked here, I'm truly confused by this post.

The housing cost is very clearly related to the issues of homelessness. Of course it's not the only thing, but it's a significant factor.

Fix housing, provide housing for the mentally ill.

Voila! You no longer have mentally ill homeless people. Like, of course the system which doesn't support people until they're able to stand on their own legs results in people repeatedly falling over.

Fixing the mental illness epidemic is another problem, one which may require better policy around housing, food, mental health services, and taxation of the wealthy. Even then we may not have the tools to 'fix' all the people who've been broken by the current system, during the lifetime, because the human brain is so complex.

But if we fix these issues, the next generation wouldn't have so many mentally ill homeless people in the first place, and we'd have better tools in place to treat people before their mental illness spirals to the point where it's beyond our current mental health care industry's capability to treat.

>in practice it’s all vibes

Vibes matter. When walking down the street, a person isn't going to do a full evaluation on a homeless person. They are going off vibes, and if the vibe is unsafe, it makes the city feel unsafe. People with money to spend tend not to go to cities and areas that feel unsafe, which over time will cause a city to die, which is bad for everyone.

>Best-case scenario, they’re completely sane. Now what? Do you keep a completely sane person locked in the mental institution forever?

....

>the social workers can’t show up at their door, because these patients are homeless and hard to track down.

...

>Okay, sounds like you need to get them homes. But there’s not enough government-subsidized housing.

Why does the mental institutions have to be "lock up"? It seems like there could be levels to this. Lockup for those who are still potentially dangerous out in society, and have something more akin to a halfway house where someone can live and are free to go and do stuff, but have a place to come back to to keep tabs on them and make sure they are taking their meds. Provide a path to full independence, but with some guardrails to make sure they are doing it in a way where they have a place to live and are taking their meds, and not just throwing them back on the street and expecting things to be different than when they were picked up off the street.

This will probably be expensive, but looking at what the homeless problem has cost some very expensive cities, it seems like it would be worth it.

I love love love that we're having these discussions about housing first and tiny homes, what if the homeless damage them, let's build (new) traditional custodial institutions for the violent, and so on...

...at exactly when architectural Brutalism is having a critical revival, don't tear down the Moriyama Science Centre, look at those beautiful Brutalist churches...

We scrounge ratty old buildings for inadequate, dangerous shelters, and haggle and whinge to the point of inaction about housing people in shipping containers or surplus hotels, but laud "jail cell chic".

It goes to show that "The cruelty is the point", that "We'll give you the world if only you bow down before [our economic truisms]". Some people have taken into their hearts that human suffering is a renewable resource.