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Michael Totten joins City Journal editor Brian Anderson to discuss the issue of homelessness in his hometown of Portland, Oregon.
Portland is often called the “City of Bridges” for the many structures that cross the city’s two rivers. Underneath many of those bridges are homeless encampments complete with tents, plastic tarps, shopping carts — and people.
Oregon’s Supreme Court has blocked efforts to regulate homelessness in Portland, leading the city’s political leaders and nonprofits to explore new options as the situation has worsened.
City Journal is a magazine of urban affairs, published by the Manhattan Institute.
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Thanks for doing this Podcast. Michael totally hit the nail on the head when he describes the problem around minute 6: you really cannot talk about homelessness without talking about mental illness and addiction as well. And a big part of the problem is that many homeless people do not want to get better: indeed, if you have an addiction problem and repeatedly refuse to seriously confront it, this is where you eventually end up, after having exhausted your social support network. I have a friend from high school who is currently homeless back in the city I grew up in, due to her schizophrenia and her refusal to stay on medication. She went from staying with every friend she had in turn, one by one, until she had burnt every bridge and friendship with her destructive cycles of her illness. Then she would move out of their house and end up back on the street. It’s a heartbreaking problem, because the homeless person is a victim in a sense, but often also a victim of their own vicious cycle.
@icarus213, people who can’t take care of themselves used to wind up in the state hospitals.
And Totten is missing part of the story.
From historian Clayton Cramer’s My Brother Ron: A Personal and Social History of the Deinstitutionalization of the Mentally Ill:
Rather than being reformed, the system was deliberately wrecked by radical activists who coopted the reformers who helped persuade budget conscious politicians like Reagan.
And:
(Emphases added.)
Erratic and violent behavior that used to get people locked up in mental institutions is now on the streets; the violent mentally ill aren’t removed from society until after they kill someone.
I moved to Portland in August, and work in an Emergency Department in downtown. I’ve never seen so much homelessness and drug use. It’s such a massive drain on our healthcare.
The fact is that unless people have committed a crime, they have a right to be free.
I am old enough to have had a friend institutionalized in one of the mental hospitals that were shut down, and I am grateful that they were. No one deserved to be treated that way.
Conservatives make me laugh on this issue. Conservatives ridicule liberals (as do I) when they say that welfare programs would work if only the country put more money into our welfare programs. Conservatives know that the government can never be the caretaker of people it says it will be if only it had more of your tax dollars to work with. Yet the same people think the government can run a mental hospital humanely, not lock up the wrong people, diagnose people properly, and treat them properly.
Trust me. The government cannot run mental hospitals. The government only understands prisons.
Since you seem like someone who may have some more detailed thoughts on the subject, do you have anything prescriptive to add?
If we agree that homelessness is not a good thing, what should be done about it?
And what should be done to help the subset of the homeless population that is unable to escape homelessness due to mental illness?
There is a very long answer to this, and I don’t know where to start.
I was the legal guardian for a paranoid schizophrenic for twenty years, so I know that it is possible to help people with severe mental illness.
We just need to get organized. It’s work, but everything is. :)
Sometimes it is. But:
No worries. You are under no obligation to expound at length.
Maybe some other time.
As best as I have been able to piece together from random posts and articles on the internet, many (on the Left?) blame/credit California Governor Ronald Reagan for deinstitutionalization. Apparently, President John F. Kennedy signed some legislation to reform the mental health care system, but the hopes of removing institutionalization and replacing it with something better only ended up removing institutionalization.
So I only have a basic understanding of the situation.
My first inclination is to be skeptical of anything favored by the Left and the ACLU, but they could be right. I don’t know.
Sources (in no particular order):
That’s an interesting assertion, about the violent crime rate going up as a result of deinstitutionalization. It’s plausible, certainly. I’ve never heard that before.
I am not suggesting that mentally ill people don’t need care and help and supervision–they need lots of all of that.
Suicide was the biggest problem for schizophrenics in the past. And they were more often the victims of crimes than the perpetrators. Medication has changed the prognosis for schizophrenics. But medication is not enough. It has to be part of a whole rehabilitation program. There lies the rub. But it can be done.
I’m not sure what the latest statistics are for the homeless population–what the percentages are of drug and alcohol addicted people and mentally ill people, and just those who have given up trying to get a life together.
This much I do know for sure: there are better answers than the old mental hospitals. They were closed down because they were horrible and inhumane, filthy scary places. No one deserved it.
Some were. Some were less so, at least at times when reformers were making things better. My stepfather, A”H, was a psychiatrist with experience in the state hospitals and prisons. He thought that the state hospitals in the pre-psych med days were the least bad place for many of the inmates. He said that for many it allowed some stability and chance to form lasting relationships and community.
He was a realistic man who predicted the mess we’re in today; my mother remembers him saying that the mentally ill “will be in the parks and on the streets.” He thought his colleagues who gushed over the community mental health centers where the mentally ill would seek care were… nuts. He was right.
Along with the deinstitutionalization push from ACLU attorneyBruce Ennis (he was influenced by the radical psychiatrist Thomas Szasz, who believed that there was no such thing as mental illness; Ennis didn’t go quite that far, but his goal was to make involuntary commitment almost impossible) the ACLU was active in promoting patients’ rights to refuse to take medications including psych meds.
That’s not what was not what Ennis’ reformist allies and dupes had in mind, but it is why the escalators at San Francisco’s Civic Center BART station are so full of human feces and urine that they keep breaking down.
The thing is, if you’re going to talk about the horrible problems that that were systemic in some states and episodic in others, in order to make the risk/benefit and cost/benefit tables complete, you have to talk about the abuses due to the lack of the hospitals today.
For example, while there were certainly abuses in the state hospitals, there are also abuses on the streets and in the parks – whose denizens are often the first victims of the dangerous minority among them whose mental problems are such that they should be involuntarily confined and, when possible, treated.
If this subject interests you, I strongly recommend historian Clayton Cramer’s My Brother Ron. His brother was a paranoid schizophrenic; his experience with his brother sparked an interest in how the U.S. has dealt with its mentally ill. His book cuts between the history and his experience, with each half informing and illustrating the other. At $1.49, the Kindle book is a terrific buy.
The two choices were equally bad, in my opinion. I understand your stepfather’s point of view, and I certainly have encountered many people in the psychiatric profession who shared his opinion.
I don’t like either answer, but for me, after what I saw in my own state’s mental hospitals in the 1970s, I would never go back there. Golden rule kicking in here, I’d rather live on the street than in one of the old mental hospitals. (The worst of the situation was that when they decided to shut them down, they found many people inside them who were not mentally ill but rather developmentally disabled. It is shocking how quick people are to lock people away who are just difficult and time-consuming to care for.)
I’ve seen some assisted-living facilities that would be ideal for the people for whom no amount of medication and rehabilitation would work. That would be my first choice.
Frankly, the country is dealing with a similar problem today with high numbers of Alzheimer’s patients. Some of the locked-ward facilities are as terrible as the old mental hospitals were. Some are quite nice.
As I said, at some point we just have to get organized and tackle this, person by person.
There’s some hope of that happening with a Republican in the White House. The press has been ignoring the problems of growing homelessness for the past eight years.
We ain’t seen nothing yet. Estimates are 160,000,000 in 2050.
There are a range of genetic predispositions.
The expression of those predispositions is heavily influenced by
The disease course can be stopped and even reversed by a personalized approach; cases have been observed in which regeneration of atrophied brain structures (the hippocampus so far) has occurred.
The approach requires active patient participation; coaching is usually a very important part of this kind of therapy. Even so, it’s a whole lot cheaper than 24/7 care, not to mention the fact that you get to live with your brain intact.
The amyloid plaque which is the signature of the disease begins to deposit in the most recently active memory tracts in response to inflammation and/or infection; it is a protective response. If the process isn’t contained, it goes on to gum up older and older structures. The only drug out of hundreds trialled so far that has succeeded in producing clinical improvement only reverses the plaque deposition and produces clinical improvement if the underlying cause has been removed. With active inflammation continuing, removing the protective plaque produces rapid clinical deterioration.
Key lab markers:
There are others.
How many people are druggies and how many are schizophrenic?
Dual diagnosis (in a lot of cases.)
Michael answers this question around Minute 6 – he says about 50% of homeless in Portland had mental illness, and about 75% have some addiction problem. So there is clearly overlap between the problems.
I would absolutely agree with the stat of 50% have mental health issues- possibly even higher. However, I would like to know what percent have legit mental health disorders (schizophrenia, bipolar, vets with PTSD) and how many have “I have no coping mechanisms” mental health disorders that don’t necessitate medication and would be better helped by some talk therapy to develops coping mechanisms. There are hands down people that need our help because of their mental health disorders. But I also see a lot of people who just don’t want the responsibilities of being an adult- they would rather sit in the park and smoke up or shoot up. @1967mustangman and I talk about this frequently.
I’ve also had patients that have told me they just moved to Portland because of the rich resources for the homeless. They move here to be homeless in Portland. I’ve had patients refuse programs to help them back on their feet- they would rather stay homeless and not have to get off drugs and get a job.
While you said it before, I didn’t understand what you meant then either.
What do you have in mind?
Better mental health legislation? Private charity? 1-on-1 adopt-a-homeless-person?
Me too.
I’d also be curious to know the percentage that are
This in no way diminishes the extent or seriousness of PTSD (which is not just for vets, either) but not every homeless person who claims to be a veteran is. All too many are, but not all who claim to be are.
Just the other day I spoke with a pleasant twenty something person two years out from a TBI. Energy is still low, still gets headaches most days that affect performance at the new job – but hasn’t mentioned it since still on the initial probationary period.
“If I had been working there when I was injured, it might be different but it’s a new job.”
A colleague with a TBI from a scooter accident (urban speeds, helmet, not at fault) had to step down from a much loved job and dial back professional activity.
Both of these people were blessed with families that could help them financially and provide emotional support, and had good social networks that helped them as well.
Look at the people on the street and think: There but for the grace of God go I.
Speaking of vets with PTSD: a 1:1 ratio between tissue omega 3 and omega 6 fatty acids is good (protection/recovery from TBI;) it’s not uncommon for young males aged 18-26 in prisons and the military to have ratios of 1:20.
hard to say, because mental ill folks will self medicate,i.e. what is the cart, and what is the horse?
People succumb to addictions and severe mental illness because of other problems. It used to be said that disease takes the path of least resistance. That same principle applies to severe mental illness and addictions. There’s a predisposed physiological pathway to a person’s unique response to acute stress. But it’s the stress that is the precipitating event. It lowers the psychological immunity, so to speak.
What causes stress? Isolation, failed relationships, and, most of all, rejection.
I look at it this way: a fever is one of the human body’s responses to viral or bacterial invasion and threat. A fever is a good life-saving thing, but sometimes a fever in and of itself can become the life-threatening problem and actually kill the person it is designed to save.
Our psychological coping mechanisms sometimes get out of control.
To treat addictions and mental illness, we need to help people find a supportive social space in which to function.
So, yes, we have to help people one at a time because the circumstances that got them to that situation are as unique as they are.
[continued]
[continued from 23]
What I have never understood is why they closed down the institutions rather than simply converting them to something like dormitory spaces.
I have always been angry about the lack of housing and supportive services in the community-based care that was dreamed about during the deinstitutionalization phase. Where were these people going to live? It was so obvious what would happen to them.
The psychiatrists got excited over the power of the new antipsychotics to fix mentally ill people. But they really didn’t think this through. And while they were dithering about without setting basic goals and objectives for the mentally ill people in their care, naturally the law stepped in and said, You can’t detain or confine people against their will.
It was a perfect storm. Why it has remained this way for so long (my entire adult life) is testament to the lack of compassion in our society generally. I’m sorry to say that I feel this way, but I do. It’s indifference.
When I stepped in to take care of my mother, I had three goals, which I wildly exceeded: to make sure she had a decent place to live, good medical care, and contact with my family and me of some limited sort.
Just meeting those goals gave her a life that was not as good as I wished it were (so much is possible) but so much better than it was when I decided to try.
In California, a lot of them were on very nice pieces of land.
One facility for the criminally insane is now a Buddhist monastery. The abbot of one of the temples associated with it told me that it took a lot of meditation to get rid of the dark presences in some of the rooms.
The part of the history here to keep in mind is that the states saw deinstitutionalization as way to save money.
That is why they embraced it.
The same thing happened shortly afterward with elderly people in nursing homes, which states deinstitutinalized.
The result? Millions of elderly people living entirely alone, no human contact except a rushed Meals on Wheels person, so overburdened that he or she leaves five or six meals at a time and has to rush in and out, without having time to chat.
The whole thing make me sad. The alone elderly are so bereft of any activities that it would be considered against nursing home regulations were they in one.
We’ve abandoned people–all kinds of people.
It drives me crazy.
But it is all mostly about money. At this point it is so bad that what would have taken a few cents to fix twenty years ago now will cost untold millions. Which means no one is going to try now. Which means a couple of generations of people who will suffer and die miserably who could have been helped.
I’ve long thought that we need to prevent homelessness–that is, look at it in terms of preventive medicine.
We know that people are at risk of becoming homeless at some predictable transition moments: dropping out from high school, graduating from high school with no college to go to, aging out of foster care, divorce, unemployment, especially long-term, eviction, bankruptcy, . . .
There are events in people’s lives that we can identify and intercede in.
That’s certainly part of it; some of the money they were trying to save was payouts in lawsuits for lawsuits by the ACLU which were intended by the ACLU to make it too expensive for the state to keep the hospitals open.
But if you look at California, which was something of a pioneer in deinstitutionalization, it was a bipartisan effort in the legislature led by legislators with a long track record as mental health advocates and reformers. IIRC, one of them himself had a seriously mentally ill family member.
While current patterns of mental illness will persist, they will be made worse and mentally normal individuals will be devastated by the looming Alzheimer’s apocalypse.
With our growing understanding of the processes by which AD develops, I think we stand a good chance of prevention there – but the best shot will not be with many of the mentally ill, since close compliance to a regimen will be necessary.
The smart money is betting against useful Alzheimer’s drugs for now, though the betting will continue because the potential jackpot is so huge.
Michael Totten’s discussion of the community for the mentally ill on public land in Portland is informative; community, either IRL or virtual, can be a powerful accountability and motivation tool for health regimens as well.
The ACLU only went after involuntary commitments.
That’s why I say there was another choice: make the institutions good places, that helped people, and most of the patients would have stayed.
There was a study I read at about the same time as deinstitutionalization occurred that compared recovery for two groups of institutionalized mental patients: one group had a room and a bathroom for each individual; the other group had a bed in a big ward, which was common back then. The group with the private rooms did remarkably better. The researchers theorized that mentally ill people, like all of us but more so, are fragile and needed to be able to retreat from the group when they wanted to. My mother was in an open ward of thirty very ill people–the scariest place I’ve ever been in my life.
The states did not spend the money to make these true hospitals. They decided it was cheaper to release the patients to nearly-nonexistent “community care.”
Sort of. That was the pretext it used to destroy inpatient care except in extremely exigent circumstances. This was an example of the “best,” (in this case Szasz’ crazy idea that the idea of mental illness was itself a delusion and how dare we confine someone because of our delusion) being the mortal enemy of the good, namely improving the institutions. To the ACLU the very idea of inpatient care was anathema and was to be taken off the table by lawfare and threats of lawfare to make it prohibitively expensive. Your mother was an egg who was scrambled so that the ACLU could make Szasz’ omelette.
Absolutely. But that’s what the ACLU intentionally destroyed. And again, the budget aspect is more complicated than just “saving money.”