[Guest Writer, Angelo Tsoukalas, has been living in Bellingham since February 2011 and loves it. He has degrees in Economics and Political Science from UCF in Orlando, FL and in part at FSU. After three years of working in his field, he opened his own business in the computer industry. He has been in business almost 30 years.]
On any given night throughout the United States, including here in Bellingham, over half a million people are homeless: sleeping on the streets, in cars, abandoned buildings, tents, or in places like the Lighthouse Mission or other emergency shelters. Almost half of these unfortunate people (250,000), have mental health problems, and as many as a quarter (140,000) have serious mental problems like schizophrenia. [“In January 2015, the most extensive survey ever undertaken found 564,708 people were homeless on a given night in the United States.” While as many as 250,000 or 45% had some kind of mental illness, 140,000 or 25% had a serious mental illnesses." References here and here.] Knowledge of this sad state of affairs would cause people like Dorothea Dix and Thomas Story Kirkbride to turn in their graves.
A Brief History
Who is Dorothea Dix? She was a 19th century nurse administrator and early activist who had a huge influence on medicine in the U.S. It is believed she was born to abusive, alcoholic parents who gave her first hand experience in dealing with mental health and addiction issues. They also instilled in her an interest in helping with these problems. Dix was a tutor during her youth, but was often ill, so her physician suggested she spend time in Europe. While there, she met other people who were also interested in reforming the treatment of the mentally ill. Upon her return, she visited and evaluated U.S. mental hospitals. She kept politicians informed of the abuses she saw and advocated for reforms of the way mental patients were treated. During the Civil War, she was appointed the superintendent of Union Army nurses. At that time, nurses were all male, but she quickly helped change that. She brought more women into nursing by setting up more training and encouraging them to join. After the war, she continued to advocate for social reforms. By the end of her life, she had restructured mental hospitals in the U.S. and abroad to better care for people with mental disorders.
At about the same time, Dr. Thomas Story Kirkbride was also trying to radically change the treatment of the mentally ill. Have you ever noticed there seem to be two types of mental institutions? One has beautiful Victorian buildings set in countrysides with wonderful airy gardens. The second has big, ugly, boxy buildings like you see in creepy movies or on YouTube where people are hunting for ghosts. You can thank Dr. Thomas Story Kirkbride for the former. He is also known for establishing what later became the American Psychiatric Association. And much like Ms Dix, he believed in reform to promote the well being of the mentally ill by designing hospitals with beautiful architecture. His hospitals allowed plenty of light and fresh air, in serene country settings with grounds for gardening and farming to allow for patient exercise and well being. Unfortunately, by the early 20th century, many psychiatric professionals felt the Kirkbride Plan, as it came to be known, did not produce results and was too expensive. So, big, ugly, mundane buildings became the new standard.
What Went Wrong?
By the 1950s and 1960s, mental hospitals had become overcrowded and were festering with abuses. Unproven, dangerous, and debilitating treatments, such as insulin shock or the most infamous, lobotomies, were applied all too often. Lobotomy proved to be a quackery of abuse that resulted in brain damage rather than treatment, and often even death. Then, influencers ranging from authors to sociologists to even President Kennedy helped change that. Books like “The Snake Pit” and “The Myth of Mental Illness” helped educate the public as to what was happening. In 1961, sociologist Erving Goffman’s writings described the prison-like state of these hospitals and how the terrible treatment was actually making patients worse than when they entered. And finally, President Kennedy had a strong dislike for the asylums because his sister had been a victim of the lobotomy quackery.
This all led to a defunding movement by the federal government and states. A single quote from Dr Mark L. Ruffalo D.Psa., L.C.S.W. succinctly captures how we got here from there:
"The idea was to close the massive state hospitals and instead care for patients with mental illness in community settings that would end their isolation from the world and recognize their rights as citizens. When funded and practiced well, community psychiatry was an enormous success. But, sadly, the money saved from closing the custodial state hospitals was often misallocated to tax cuts and prison construction—depriving the mentally ill of adequate community treatment and housing. The result has been a broken American mental health “non-system” that over treats the worried well and vastly under treats the seriously mentally ill. Instead of 600,000 in state hospitals, we now have 350,000 mentally ill in prison and 250,000 homeless-because the vast majority is unable to obtain decent housing and access to treatment." [Reference here.]
And may I add, growing exponentially!
If we step back and look where we went wrong, would we not find the solution? Since community psychiatry “was an enormous success” when funded, it should be the solution. It should include addiction treatment, since most mentally ill are also addicted. Advocacy groups need to encourage people to contact their representatives and urge them to fund community psychiatry and addiction treatment in a community type hospital or tiny house community with a local office, providing these much needed services – otherwise we have to go back to the big state hospitals because this is not working. When people with mental health issues are moved from the streets and the nonviolent from jails, and instead provided housing, addiction services, and psychiatric treatments in this kind of setting, people will begin to see the benefits: fewer people sleeping in the cold or terrorizing neighborhoods with crime, drugs, debris, used needles, urine, feces and violence.
This will free shelters to help individuals and families who are down on their luck. It will free law enforcement to spend the majority of their time dealing with criminals instead of mental health and drug related issues. Once we see some success, support will grow to make this the standard way of getting people off the streets and into treatment.
In the 1970s and ‘80s, we systematically began shutting down our mental institutions without adequately replacing those services. Our homeless population burgeoned. Recently, state after state has been taking steps to “Defund the Police,” and/or adding more rules on how they police, hoping to prevent abuses but also causing the police to be less effective. Our homeless problems and related issues are about to get exponentially worse. We need to acknowledge that we cannot have a civilized society, cannot expect humanity, peace, and safety, at the same time we have an ever growing underclass of homeless people suffering on our streets from drug addictions and mental health problems. We need to take care of this by taking care of each other. Above is a graph from Whatcom County displaying the rising crime rate in the past six months. Of course it doesn't account for non-reported crime and unfortunately counts the biggest crime only in cases of multiple crimes during an incident – see note on chart.
Comments by Readers
Ray KamadaNov 12, 2021
I agree. The history of homelessness is a horror story.
I recall then California governor, Ronald Reagan, seemed delighted to use slogans like “family values” to close all the state wards, leaving the mentally ill to fend for themselves. But it wasn’t just the conservatives who caused this. One lefty friend handed me a book by R.D. Laing, about the patients’ right to self-determination. Being a bit naive, I almost bought it until one housemate - a physician and 1st year resident at Sacramento General, went actively bonkers. “I’m the reincarnation of Cleopatra!”, etc. She showed me that when you’re gone, you’re gone; left untreated, “self-determination” won’t bring you back from La La Land.
But nowadays I think the issue of homelessness is like seven blind men describing an elephant. One has an ear, others a tail, a trunk, a leg, etc. Few of us see the whole picture. I certainly don’t.
Also, I don’t subscribe to defunding cops. Instead, they should be an arm of Public Safety, with 911 getting better training to dispatch who to send first - police, fire and rescue, or social services.
Satpal SidhuNov 14, 2021
This article reminds many people that the issue of homelessness and behaviorial health crisis in communities in USA is creation of past 50 years of neglect and indifference by Federal and State governments. Local governemnts (specially small jurisdictions like Whatcom County) do not have enough resources to eradicate homelessness. Also just throwing money at it is also not the ansewer. We need trained professional (hard to find these days) and properly resourced facilities. We all need to work together on these issues instead of creating an atmosphere of confronatation and protestations. The blame game is a waste of time and resources and demoralizes the ones who are actually doing something about it, however small it may be.
Amanda FlemingNov 17, 2021
This article, like so many discussions of mental illness and homelessness, has major holes in it. It skips from the era of commitment to ECT- and lobotomy-dispensing institutions to today, when very few people are able to be committed to any kind of institution, or can be forced to accept mental health treatment or psychiatric medications.
Also, “mental illness” needs to be defined, as well as the extent of disability due to a mental illness. Mental illness may include everything from depression to a psychotic break.
“More mental health treatment” or “community-based mental health treatment” is useless if people won’t accept it. I want to scream when I hear for the millionth time that we need “more mental health treatment,” as if people would come running and line up all night for it. We actually do have clinic-based “mental health treatment” that is widely available. But the state hospital closures went hand-in-hand with a major reduction in the ability to require mental health treatment. Here is a quote from “Psychiatry Online”: “The reforms in civil commitment statutes that occurred in the late 1960s and early 1970s led to profound changes in both substantive and procedural aspects of involuntary hospitalization. One such change, the addition of the requirement that persons affected by mental illness be either a danger to themselves or others or gravely disabled, required that this determination be made before initiation of long-term commitment proceedings and that evidence of the determination be available in a commitment hearing, The term “gravely disabled” refers to a person who, because of a mental illness, is unable to meet his or her basic needs, including the ability to meet the need for food, shelter, and basic self-care.”
What this means is that unless someone poses an immediate danger to themselves or others or is gravely disabled, as defined above, you cannot force them to get mental health treatment, much less commit them. We also cannot compel addicts into treatment. Virtually all of the homeless qualify for Medicaid, which will pay for treatment. However, the majority of homeless people who are disabled by mental illness have no desire for “mental health treatment” and/or motivation to cooperate with such treatment. They may not trust mental health providers (an attitude not limited to the homeless), may not want to cooperate with conditions of treatment, such as weekly appointments, may dislike the side effects of psychiatric medications, or may not agree that they have a mental problem.
I learned about these issues when I worked in a support position in a nonprofit mental health clinic. I learned how hard it is to convince people with disabling mental illnesses or addiction or both to get treatment or continue with treatment. It’s also harder than hell to house them. I saw counselors work very hard to get housing for clients (which was not even technically part of their job but they did it anyway), but people with serious mental issues often do not stay housed because they either cannot or will not cooperate with others to the extent necessary to retain housing,
My view is that we first need to change the laws that restrict our ability to compel people disabled by mental health issues to get treatment. We cannot provide services to people in ANY setting unless we can figure out how to get them there and keep them there in the first place.
Satpal SidhuNov 17, 2021
Dear Amanda, I really appreciate your input on this subject. It is always advocated to the government to invest more provide more professionals, but there is no urgency for people who need help to be brought in and treated.
Amanda FlemingNov 17, 2021
Thanks so much for your response. I see where I may have put things in a way that I did not mean to say. When I talked about “compelling people to get treatment” I wasn’t talking about locking them up, unless they are dangerous. Mainly I was thinking about requiring people to take psychiatric medications and meet with a prescriber to monitor their condition, in severe cases when that is clearly indicated, and perhaps tied to some benefit. This may sound harsh but it is harsh to allow people who are disabled by mental illness to live on the streets in a condition that makes helping them very difficult. This is of course not the answer for everyone, because there are many kinds of mental disabilities and medication is not always indicated, but it would help many of the homeless who are not rational and who are most likely to cause people to wonder “why we don’t have more mental health treatment.” Of course this would not be easy to accomplish either, and would not work for everyone, but I have seen tremendous improvements in patients whose conditions can be treated with medications and who consistently take their medications. This can make all the difference in someone’s ability to function.
Satpal SidhuNov 18, 2021
I totally undersantd and I am of the same view. This is in way meant to put people back in institutions (like the answer was 100 yeasr), but to proactively encourge them to seek regular check up / treatment and follow up. But just leaving them alone without any proactive action from people having these issues, until it blows up into serious issies or incidents in not the answer.
Also the stigma attached to mental helath is not very helpful for all citizens.
Angelo TsoukalasDec 04, 2021
Amanda and Septal,
I understand everything you are saying and appreciate it. This article and the next one, Part II are designed for these discusssions. Yes I agree Amanda, rights to those that can’t help themselves due to mental illness end up cold in the rain and not helped because everyone’s hands are tied by legalities. At the end the public in those areas suffer because they are robbed or abused by the same. Thus maybe these legalities can be peeled back enough to get these people real help, by those in power, our congress, with what I suggest; or who knows maybe from these disucssions we’ll discover an even better method. In the ancient times my ancestors in ancient Greece would sit and listen to all kinds of new and even old forgotten ideas - just to hear something new, different or even forgotten. And as long as they did that - they lived the golden age of Ancient Greece. However when they stopped such peaceful discussions and resorted to animosities and in fighting… well anyone that knows their history knows what happened. If you don’t, then you better get busy reading becuase ignorance is not an excuse to the Creator.