From Mean Streets to Mental Hospital Is No Cure for Homelessness
The appalling spectacle of mentally disordered homeless people aimlessly wandering the streets and sleeping in doorways has justifiably alarmed the public and the lawmakers. But consigning greater numbers of the nondangerous disordered to state hospitals by broadening the commitment laws will not solve the problem. A hospital is not a home or, in most cases, the best setting for treatment.
We must simply accept that there are insufficient resources and technology to care for, treat and rehabilitate more than a small fraction of chronic and severely mentally disordered people. Substantial misery and degradation is unavoidable, no matter what policy we adopt. The real question is how to do the best that we can for the mentally disordered and for society as a whole.
The expanded use of involuntary hospitalization will not help non-dangerous disordered persons, because we will not spend the money necessary for adequate care and treatment of increased numbers of inmates. Deinstitutionalization over the past three decades was motivated largely by the recognition that state hospitals are often human warehouses with limited therapeutic potential and that community care is preferable to involuntary hospitalization. Deinstitutionalization wasn’t really tried, however. The in-patient population dropped about 80% nationwide in state and county mental hospitals, but the resources and community institutions necessary for successful deinstitutionalization weren’t provided.
Even today, with reduced numbers of patients, the state hospitals have insufficient resources to provide adequate drug therapy, the most efficient form of treatment for the severely disordered. Moreover, the present hospital system cannot provide rehabilitation for the large numbers of people who need these services. Drugs may reduce crazy thinking, agitation and other symptoms, but they do not cure underlying pathology and they cannot teach persons to hold jobs, manage a budget or achieve the myriad other skills necessary for independent living.
If our society was and is unwilling to provide resources for decent treatment, it is naive or cynical to assert that we will spend enough in the future for expanded and ever more expensive hospitalization. We can only justify the infringement of liberty that involuntary hospitalization represents for non-dangerous disordered people if their condition improves--the discomfort that they may cause us is insufficient moral or legal justification. And no convincing evidence suggests that “reinstitutionalization” will provide the severely disordered with humane care and a reasonable chance for an autonomous life.
Broadened commitment criteria, even if they appear sensible and require treatment, will be abused. Studies of states with narrow commitment criteria demonstrate that one-third to one-half of persons committed did not really satisfy the statutory criteria for commitment. If the commitment criteria are broad, pressure to remove the disordered from the community will inexorably produce even more overcommitment.
We will simply trade visible misery and degradation in the community for invisible degradation and misery in overcrowded and understaffed institutions. The only major published study of the effects of reinstitutionalization found that in the state of Washington, which broadened its hospitalization criteria, the state hospitals are once again overcrowded, adequate treatment is unavailable, many persons who were able to live in the community without hospitalization are now committed for long periods, and, most ironically, there is insufficient room for patients who voluntarily seek help. We probably will not allow state hospitals to become snake pits again, but who will pay the massive costs if the patient population increases?
The proper response to non-dangerous mentally disordered persons is to allocate sufficient resources to provide community-based treatment and rehabilitation. Many comparative studies demonstrate that community care is less expensive and as effective as in-patient hospitalization; in fact, a recent Vermont study demonstrated that it is feasible to dismantle the state hospital system entirely and replace it with a network of community services. Self-help and advocacy groups run by former patients are another promising approach that should be supported. Finally, we should change the provision of care incentives to ensure that far greater numbers of the most talented mental-health professionals work with the severely disabled, rather than with the “worried well.”
Homelessness is basically a social-welfare problem. It is not produced primarily by mental disorder. Few rich disordered people are sleeping in doorways, and many homeless people are not disordered. Involuntary hospitalization is not a sensible means of providing shelter to the needy. Excluding the mentally disordered from our communities will only permit us to avoid confronting the misery.
