The Atlantic has a long book excerpt titled “American Madness: Thousands of people with severe mental illness have been failed by a dysfunctional system. My friend Michael was one of them. Twenty-five years ago, he killed the person he loved most.” The story is about a brilliant man named Michael Laudor, who was also a schizophrenic and as a consequence of schizophrenia killed his pregnant fiancee while in the grips of delusion. The story is partially about what the author, Jonathan Rosen, calls “the wreckage of deinstitutionalization, a movement born out of a belief in the 1950s and ’60s that new medication along with outpatient care could empty the sprawling state hospitals.” Rosen says that:
During the revolutions of the ’60s, institutions were easier to tear down than to reform, and the idea of asylum for the most afflicted got lost along with the idea that severe psychiatric disorders are biological conditions requiring medical care. For many psychiatrists of the era, mental illness was caused by environmental disturbances that could be repaired by treating society itself as the patient
It turns out, however, that many psychiatric disorders are in fact biological conditions, rather than being caused by “environmental disturbances.”* The environment might exacerbate or mitigate some psychiatric challenges, particularly for things like psychopathy, but the psychiatric challenges remain. We’ve written grants for lots of mental healthcare providers that know how mental health challenges exist on a spectrum: someone with ADHD or many forms of depression might be addressable in a straightforward, outpatient manner, but schizophrenics and people suffering from other severe and persistent mental illnesses (SPMI, which is the current descriptor of choice in the grant writing biz) aren’t well suited to basic outpatient treatment. A lot of the online discourse around mental illness concerns people with issues that may be serious, but that are unlikely to result in fundamental breaks with reality, homelessness, and murder.
Rosen reports what I was discussing in the preceding paragraph—that some people don’t fit well into the outpatient model:
One problem was that nobody knew how to prevent severe mental illness; another was that rehabilitation was not always possible, and could only follow treatment, which was easily rejected. And despite having been created to replace hospitals caring for the most intractably ill, community mental-health centers, as their name suggested, aimed to treat the whole of society, a broad mandate that favored a population with needs that could be addressed during drop-ins
People with SPMI who aren’t involuntarily institutionalized often end up on the street, which is obvious to anyone who’s visited San Francisco, or parts of L.A., Denver, Seattle, or any number of other cities, which have been struggling with a combination of high housing costs, limited policing, and few tools to compel treatment. Rosen says that “The biggest improvements in people’s mental health can happen when they are involuntarily hospitalized, a psychiatrist who works with the homeless told me.” A lot of mental health services organizations and homelessness service organizations will admit as much in private—we know, because we’ve been on those calls—but they’ll almost never say so in public. Saying so is too incendiary, and too contrary to the hopeful messages of the ’60s, which still resonate in American culture today.
As a society, for various reasons, we’re not willing to have hard, honest conversations about tradeoffs and challenges. Freddie deBoer has a review essay of Rosen’s book that picks up these threads; he writes that “I look and look for some grappling with the messy, sad, sometimes tragic reality of mental illness in major media and I find nothing.” The reality is often not suited to the dominant narrative, and we’d prefer to ignore the reality. Foster family agencies are similar: they deal with issues that have no good answers and that most people would prefer not to think about. So most people don’t think about them.
Most people prefer not to think too hard about how to deal with SPMI, but reality can find its way through that preference to consider something else. Michael Laudor’s fiancee likely didn’t think she’d die by his hand, and preferred to think that she’d be okay, and that she could save him, when only medication, taken as scheduled, could. The severely and persistently mentally ill generally can’t be confined for more than a few hours or days until they commit a serious crime, even if their journey towards serious crime is evident to their loved ones.
We don’t yet know what happened to Cash App founder Bob Lee, who was murdered on the streets of San Francisco, but chances are SPMI played a role. It’s likely that his murderer, if he’s found, will have a long criminal history as well. The proximate cause will likely be something crime-related, or related to that particular day’s episode, but the ultimate cause will in part be that “dysfunctional system” Rosen writes of. Emergency rooms and police officers aren’t alone going to fix the system we have. Not even federally qualified health centers (FQHCs) and other kinds of behavioral health services providers will, or can. They can be part of the solution, but a big part of the solution has to be something we’ve not been willing to countenance since the ’70s. The alternative is the status quo: more Bob Lees and more murdered girlfriends. While Americans sort this out, the failure to deal directly with SPMI is contributing to the rapid decline of the quality in many cities. While San Francisco and Seattle are very beautiful, many folks will likely think twice before venturing to either for a vacation or conference, as they think: “who needs the risk?”
* Very few people today take Freud seriously, except as a storyteller, for obvious reasons.