The LA Times had an article by regular staff writer Thomas Curwen about the ideas of sociologist Andrew Scull, a professor at UCal San Diego. It seems that the history of mental health treatment contains some shocking episodes - from the days before most of us were born. No, really. The attempted treatments included lobotomies in the 1940s, electroshock therapy. This is all news to you, I'm sure.
Here's a tip when reading articles about whatever public mental health issues are troubling us now. If they think it's really, really important to tell you about how terrible treatments were decades ago, it should be a clue that they haven't got much in that vein to tell you about now. They are setting the stage about how horrible the practitioners of mental health must still be, because, because, well, look at what they used to be. We are still doing it all wrong, you see. We must not be listening to sociologists enough.
If this seems reminiscent of things like the 1619 project or reminding us that Jackie Robinson broke the color line like about last Tuesday, well yes, that occurs to me as well. It puts me in mind of a young man speaking in Hyde Park who was very earnestly trying to show us the advantages of socialism by describing to us the mistreatment of miners trying to organise - in 1827. I asked (because yes, I am the sort of person who would challenge a Hyde Park speaker. It used to be expected but no one was doing it to any of them. It seemed a custom that needed to be preserved) "Have you got anything more current? Because I'm not seeing the point, here." Doctors didn't wash their hands between patients in the 19th C, too. We didn't have seat belts and we let people drive drunk in the old days. Thousands of soldiers died in training exercises in WWII. And I know you will scarcely credit this, but there was a time when you could cut hair without a license. The past was barbarous.
We try to give more attention to what is happening now.
Then there is the expected reference to deinstitutionalisation and all those patients released to the streets, and we now know because of all the needles and feces on the streets of San Francisco, that that didn't work. Scull, and Curwen, seem quite convinced that this happened because we adopted the medical model, the chemical explanations of mental health.
I should give some credit. They are talking first about mental health policy, not treatment. It's a better target. They have a point on that. But looking at the deep history and what that says about us as a society? Please. Let me make it simpler. Enforceable mandated outpatient medication and random drug testing for those who have received a commitment from a probate court. That's plenty expensive in itself, likely more expensive than any state wants to afford. Labor intensive. Lots of outreach, lots of people with trained eyes checking in. And it is intrusive enough that people avoid it and they can be effective at challenging any commitment or return to the hospital. There are plenty of attorneys who love the idea of bringing down large institutions like hospitals or mental health centers. Because we're fascists, you know?
Deinstitutionalism worked great. It really did. My hospital had about 3000 patients at its peak and now has about 150. It is one of the most expensive items in the state budget. So you think that still having 20x more hospitals is sustainable? Most of the people who left those hospitals - BTW you should do the arithmetic and figure out they are mostly gone now, so talking about JFK and 1963 isn't precisely enlightening - got to live some sort of real lives, and had more freedom, got married, held jobs, had children, joined churches. Medicines did that. What goes wrong is when people don't take those medicines. Or abuse substances. That's a bad combo with mental illness.
There's good reasons for that. Many of them have uncomfortable or even humiliating side effects - weight gain is a biggie - and people who have brain illness sometimes forget, especially if they don't have insight into actually needing them. Most states have little or no ability to enforce outpatient medication adherence. New Hampshire is one of the few states that does, and the ACLU hates us for that, always looking for ways to undermine or overthrow it. I get it that there is abuse of the outpatient commitments - I was one of the great predators on MHCs overstepping what the law allows and I used to teach what is allowed and what isn't. It was part of my education in the 1980s that kind-hearted liberals working in human services could be fascists in wanting patients to be kept locked up until they had learned their lesson. Not that conservatives were any better, you understand. They were also controlling and often threw in being insulting for good measure. It's just that I hadn't expected the Nice People to be essentially the same as the Mean People. I digress, as usual.
I heard plenty of psychologists, psychiatrists, psych nurses, occupational therapists and social workers - very especially social workers - railing against the medical model and forever pointing out that the mentally ill tended to come from poor neighborhoods and had bad interactions with the police and other authorities, and that this was the source of their problems. Yes, I knew people who insisted that poverty caused schizophrenia. In second place was Family Systems theories, that crazy families were presenting their children with insoluble dilemmas which led to their irrational-seeming decisions. Third place was borrowed from the psychologists, with all the hundreds of derivatives of dynamic psychology.
Anything but genetics. Literally any other cockamamie theory could get a hearing. If one of your parents had a mental illness, that only showed how having a mentally ill parent could make you crazy. The social histories were replete with evidence of aunts and uncles, grandparents they never met, or cousins that had an illness, but somehow it would still be worked out that this family's general dynamics permeating multiple generations - or the stigma of living in a bad neighborhood, or being the wrong ethnic group, was what caused the illness.
Let me interject here that actual trauma is a different kettle of fish. That can actually damage children (and adults), setting off an inherited illness or even damaging an otherwise healthy personality. It is highly unpredictable, so those who seem less affected have some tendency to be dismissive of those who went through similar things and have symptoms. I worked with a young psych nurse who was very unsympathetic to women her age who had been sexually abused by their fathers and attributed symptoms to that, because she had been as well. "Get over it. It happened to lots of (redacted ethnic group) girls. Sometimes it does defy description. My two Romanian sons lived lives of poverty and abuse nearly unknown in America. One shrugged it off as soon as he got here, the other a few years later. It seems unbelievable to me. I carry childhood resentments and have to catch myself when I remember this. Son #5 was flat out rejected by both parents (it got better later, after he had been with us a while). Military PTSD shows similar variation. In general, the more combat, the more death you saw the more likely you are to show symptoms. But it's ridiculously variable. In all trauma, coming from a culture that expects terrible things seems to be protective, which is perhaps why boys, who are beaten up by older children 5x more often than girls just shrug it off, and girls in heavy sexual abuse cultures more often do the same. Not reliably, but measurably.
But now Scull, and Curwen reporting, seem to think that going back to those days when we couldn't do anyone any good is the way to go. We shouldn't look to chemical and medical solutions, because the problem still isn't solved. We have to go back and do what I have been telling you to for years, you fools, you fools. It is not in the least shocking that now the LATimes gives him more of a hearing because everyone can see that something has gone wrong.
Homelessness is a mental health and drug abuse problem. More housing won't touch it. I did like getting ahold of programs that would spring for first-and-last month's rent, or magically, ongoing help with rent, sure. But that is because landlords will put up with a lot more grief if someone has cash, especially reliable cash, because in poor neighborhoods they have people not paying rent anyway. But my people were always scrambling because at the last place they had let other people move in. Drug dealers, sex offenders, midnight screamers. Neighbors don't like it, and neither do the police.
I hope it's not all of California, I hope it's just people writing for the newspapers, but for some reason we keep hoping that all this will be a societal problem. We would find that vindicating, somehow. It's those bad selfish people. It's our attitudes. Well, not me, not most of my readers here, but you take my point. We still think it would be great if a sociology professor could just provide us with some insight into ourselves - meaning our political opponents, mostly, but you know, society.