https://www.economist.com/united-states/2022/12/19/is-forced-treatment-for-the-mentally-ill-ever-humane

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[                    ]
United States | Care or confinement

Is forced treatment for the mentally ill ever humane?

Worsening homelessness prompts new mental-health policies in
California and New York

[20221224_U]
Dec 19th 2022 | Los Angeles and New York
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IN AMERICA'S big cities, a walk down the street or a wait for the
subway can be an exercise in avoidance. Scores of commuters in Los
Angeles, New York and elsewhere don metaphorical blinders every day
in order to ignore those sleeping fitfully on the train or battling
psychosis on the street. Such indifference is morally fraught, but it
is also a reflection of how common homelessness and public displays
of mental illness have become.

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Most Americans who experience homelessness do so briefly. They stay
with family or crash on a friend's couch until they can afford rent.
(The lack of affordable housing is the biggest driver of
homelessness.) The Department of Housing and Urban Development's
latest count of homeless people, tallied on a single night in
January, found that 22% of them are "chronically homeless", and that
there were 16% more perennially homeless adults in 2022 than in 2020.
Many live in tents beneath highways or in public parks. They are more
likely to be suffering from drug addiction and mental illness, both
of which can be made worse by living on the streets. The number of
people sleeping outside has increased by roughly 3% since 2020,
cancelling out the modest decline of people in shelters. As the ranks
of unsheltered people have grown, an old question re-emerges: how
should government help people who may not be able to help themselves?

The places most troubled by this, New York City and California, are
trying to find an answer. Both have enacted policies aimed at people
who are homeless and suffering from a psychotic disorder, such as
schizophrenia. Yet they differ in important ways. Last month Eric
Adams, the Democratic mayor of New York City, instructed police and
first responders to hospitalise people with severe mental illness who
are incapable of looking after themselves. Mr Adams's plan is a
reinterpretation of existing rules. Law-enforcement and outreach
workers can already remove people from public places if they present
a danger to themselves or others. But now, the mayor stressed, people
can be hospitalised if they seem merely unable to care for
themselves. "It is not acceptable for us to see someone who clearly
needs help and walk past them," Mr Adams proclaimed.

The mayor's plan follows a policy change on the opposite coast. At
the urging of Gavin Newsom, California's Democratic governor, the
state legislature passed the Community Assistance, Recovery, and
Empowerment (CARE) Act in September , creating a new civil-court
system aimed at directing the mentally ill and homeless to treatment
and housing. Patients can be referred to CARE court by police,
outreach workers, doctors or family members, among others.

Acceptance into the system means court-ordered treatment for up to
two years, after which patients can "graduate" or, potentially, be
subjected to more restrictive care, such as a conservatorship.
California has been quick to try to distance CARE court from New
York's apparently more punitive response. "It's a little bit like
apples and giraffes," says Jason Elliott, Mr Newsom's deputy chief of
staff. "We're both trying to solve the same problem, but with very
different tools at our disposal, and also really different
realities."

The biggest difference between the two policies is their size.
Because New York City recognises a right to shelter, the vast
majority of the roughly 68,000 homeless people there have a roof over
their heads. Experts reckon that Mr Adams's order may at first affect
only those few hundred people in the most dire straits. The
California Policy Lab at the University of California estimates that
10% of unsheltered people in Los Angeles who took part in street
outreach programmes had been diagnosed with a psychotic disorder of
the kind that CARE court is supposed to help manage. Because more
than 100,000 Californians are sleeping rough, the state thinks that
up to 12,000 people may initially be eligible for treatment.

A swinging pendulum

The schemes may be different, but the outrage they inspire is
similar. Any discussion of compulsory treatment for the mentally ill
is tangled up in a decades-long fight over the balance between
protecting people's civil liberties and bodily autonomy, and ensuring
their safety and that of others. Officials and critics alike are
squeamish about any reform that evokes the horrors of state-run
asylums in the 20th century, which were often unsanitary, overcrowded
and understaffed, and sometimes just cruel. When government-run
hospitals were shut down, community-based care was supposed to take
their place. Instead, patients were often discharged to underfunded
boarding houses and shelters. "We have not only abandoned people with
severe mental illness to the jails, but also to the streets," says
Elizabeth Bromley, a psychiatrist at UCLA.

Many liberals blame Ronald Reagan for the government's abandonment of
mentally ill Americans. As governor of California in 1967, Reagan
signed a landmark bill for patients' rights, but then cut funding for
mental-health care. As president in 1981, he rescinded federal funds
for state mental-health services. But Alex Barnard, a sociologist at
New York University, argues that heaping blame on Reagan is too
simple. "Many administrations in California have had opportunities to
reverse Reagan," he says. Perpetuating the myth of Reagan's total
culpability, he adds, is "a way of distracting ourselves from the
real challenge of building a system today that meets people's needs,
rather than just wishing we had it 50 years ago."

Civil-rights advocates in both states worry that the new policies
herald a swing of the pendulum back towards confinement. It is
unclear how often mentally ill people are detained for examination or
treatment, but recent research suggests that the average yearly
detention rate in 22 states increased by 13% between 2012 and 2016.
Many critics argue that involuntary treatment is not only brutal, but
ineffective. But the evidence is mixed and conducting research is
tricky, says Mr Barnard. "You can't randomly assign people to
voluntary and involuntary treatment if you think that somebody is at
risk of killing themselves," he explains. Mr Adams's plan and Mr
Newsom's CARE court both aim to exhaust options for voluntary
treatment before mandating medication or hospital.

Logistical questions abound, too. Luke Bergmann, the director of
behavioural health services in San Diego County, worries about how
severely ill, often isolated patients are supposed to travel to their
court appointments, and whether there will be enough beds in
long-term care facilities to house them. Watchdogs on both coasts
wonder what kind of clinical training police will receive, and
whether racial bias will lead to worse outcomes for black and
Hispanic homeless people. Brian Stettin, Mr Adams's senior adviser
for mental health, admits that confrontations with police can be
traumatic, and stresses that cops will work alongside medical
workers.

That Mr Newsom and Mr Adams are rethinking involuntary treatment
reflects the failures of America's mental-health system, but also
their recognition that homelessness represents a political problem
for their administrations--and their careers. As unsheltered
homelessness has grown, Americans have become accustomed to public
displays of profound suffering. Californians routinely say that
homelessness is one of the most important issues facing the state;
New Yorkers worry most about crime.

Allowing the mentally ill to languish in the streets contributes to a
feeling that public safety and quality of life in America's biggest
cities are deteriorating. Mr Newsom and Mr Adams are two of the
Democratic Party's most charismatic and ambitious politicians. Should
either seek higher office one day, they will be asked what they did
to solve the hardest problems in their respective domains. Now they
will at least have an answer.#

Stay on top of American politics with Checks and Balance, our weekly
subscriber-only newsletter, which examines the state of American
democracy and the issues that matter to voters.

This article appeared in the United States section of the print
edition under the headline "Care or confinement"

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