Friday, January 26, 2007

Wretched refuse.

The caption is, of course, from Emma Lazarus' poem, The New Colossus (see here), but this isn't a screed about immigration. Instead, it's about people among us now, regardless of citizenship or residency status, who we too often regard as, simply, trash.

I'll begin by recommending another blog, Nurse Ratched's Place, written by Mother Jones, R.N., a psychiatric nurse. She mixes perceptive social commentary, focusing, of course, on health care issues, with sprightly reviews of the fiction genre that could be called "nurse lit". What I'm linking to here is in the former category. MJ doesn't harangue us in her post; she doesn't propose any changes in social policy. She just tells a story and lets us draw whatever conclusions, if any, we might. She also gives us a powerful simile; one to which an architecture buff like me can easly respond.

Shortly after reading MJ's post, I came across a long discussion on MSNBC of the horrifying Kendra Webdale incident. Back in 1999, Kendra, a young woman who had recently moved to New York City, was pushed to her death under a subway train by Andrew Goldstein, who had been diagnosed as schizophrenic and had a long history of violent behavior. A condensed account of the MSNBC piece, by producer Lee Kamlet, is here.

It may seem quite a leap from the harmless bag lady of MJ's story to Andrew, whose "voices" led him to kill, but both may be susceptible to the same diagnosis, and each has been a client of the system provided by a great city and state to help those in such circumstances. It appears that the bag lady's experience with the Chicago system was satisfactory, though she may simply have been lucky to have been delivered into MJ's care rather than that of someone less compassionate. By all accounts, Andrew's experience was much less successful.

The question of what shall we do for, or with, people like MJ's bag lady and Andrew used to be answered like this: if they seem dangerous to others or themselves, or even if they seriously disturb the public peace (and assuming they don't have family who can afford private care), they should be put away in facilities that will offer them treatment as well as separating them from the rest of us. In accordance with the principle of economy of scale, these were usually very large complexes in relatively isolated places. During the late 1970s, I worked for a time as an in-house lawyer for the electric and gas utility company serving Rockland County, New York, on the west side of the Hudson north of New York City. On my way to work, I would drive past one of these facilities, Rockland State Hospital, consisting of a number of large, forbidding looking buildings scattered over perhaps a square mile of land. One of the engineers at the utility company told me that, back during the 1950s, he noticed a spike in electric demand every Wednesday afternoon. When he inquired about the reason, he found out that this was when inmates at Rockland State were administered electroconvulsive therapy.

This system began to be questioned seriously in the 1960s, perhaps as a result of the civil rights movement's having focused attention on misuse of state power over individuals. At the end of that decade, Frederick Wiseman made the infamous film Titicut Follies (see here), which exposed the horrors of a Massachusetts asylum. The resistance to the continued "warehousing" of those with mental illness resulted in stronger legal constraints on commitment to institutions, as well as efforts to establish halfway houses and clinics for outpatient care. Unfortunately, these last too often proved inadequate, as the history of Andrew Goldstein attests.

Why have we, as a polity, resisted providing adequate services for these people, even though we could thereby avert many tragedies such as that of Kendra Webdale? I think several factors are involved here. Consider the first comment, by "Mike", offered in response to Lee Kamlet's article linked above, and which (to save you having to reopen the link) I've reprinted verbatim below.

A terrible crime comitted by a mentally unstable human being, which ultimately leads to a new law and an increase in tax payers pockets, because the sick person needs our help? My heart goes out to the family. I would not help any criminal, I would send them all to death row. The fact that this happens in a large city is not the surprise, the fact that more security is needed in subways after dark is no surprise either.I hope people find ways to get smart in this century. Perhaps with less denial and more assertive inteliigence, the country and it's cities will do what is right for themselves, even if it means getting tougher. With the population growing, ego's inflating, self-involvedment & selfishness overwhelming,there are people who are basically worthless, so it's time for those who are able to make positive changes for the country do so, step up, and make it happen. Is this you?

This comment seems to me to exemplify what Philip Slater calls the Toilet Assumption, which, along with its Janitorial Corollary, is succinctly defined by Todd Gitlin in his introduction to the second edition of Slater's The Pursuit of Loneliness - American Culture at the Breaking Point, here. Note the statement, "there are people who are basically worthless," indicating that "Mike" considers Andrew Goldstein, and those like him, as, effectively, shit.

Beyond that, and alluded to by "Mike's" reference to "taxpayer pockets", is, I believe, a fundamental sense of mistrust, both of the putative recipients of tax-funded assistance, who are seen as somehow gaming the system, and of the "experts" who propose to assist them, who are seen as seeking to build unnecessary bureaucratic empires at public expense. This is a topic I will address further when I belatedly join in the "just society" conversation so ably begun by El Cabrero and furthered by Hipparchia.

Finally, consider this comment on Kamlet's article by "Sickofitall":

Goldstein was crazy alright! Crazy like a fox. He had the wherewithal to plan the attack, someone was going to be pushed. He should be made to feel what Kendra must have felt, sheer terror, in the moments as she tumbled before the train. Nothing the mental health society or criminal justice system could ever come close.

(Incidentally, the comments responding to Kamlet were, by I'd say a three-quarters majority, not in the vein of those by "Mike" and "Sickofitall".) While this comment alludes to the mistrust I mentioned above ("Crazy like a fox"), it also points to a third factor in play here. That is the fear that even recognizing the possibility that such a dreadful act as the killing of Kendra could arise from mental illness rather than rational calculation somehow makes her death more terrifying, because of its apparent randomness. It also puts us on a slippery slope leading towards anomie and the negation of free will. While these are not, on their face, arguments against providing appropriate treatment to the mentally ill, they do, I think, underly a wish to ignore the problem. (I'm not much of a fan of slippery slope arguments, except in those rare instances where I can use one against something that I or a client of mine wants to derail. On the whole, I'm confident that the appropriate lines can be drawn, so long as the line-drawing is left to reasonable people like me.)

I don't believe that "Kendra's Law", as enacted in New York and in similar versions in many other states, is enough. It may well be preventing some Kendra-type tragedies from happening, but I suspect that a more fundamental overhauling of the mental health care delivery system is needed. It won't be easy, as it will demand scarce resources as well as balancing considerations of public safety and individual civil liberties. But it should be done.

Addendum: On re-reading, I realize that the parenthetical at the beginning of the penultimate paragraph above, concerning the tone of the majority of the comments on Kamlet's article, seems to undermine the contention that the reason it is politically difficult to provide an effective mental health system is the prevalence of attitudes like those expressed in the comments I quoted. I think the answer is that many of the "positive" comments came from mental health professionals, or from people who either themselves had experienced mental illness or had someone close to them experience it. The responses to Kamlet appear to have come mostly from two self-selected groups: those with a stake in improving the system, and those strongly opposed to doing anything for the likes of Andrew Goldstein beyond locking them up and throwing away the key. While I don't believe the majority of Americans would express their views on this matter in quite the stark terms that "Mike" and "Sickofitall" did, I suspect that those two comments are closer to the "average" view than those of the majority of the commentors on Kamlet's article.

New and improved addendum, complete with correction: TenaciousK (click on "comments" below) confirms something I suspected; that the story about the spike in electrical demand caused by ECT is a myth. I guess the engineer was just pulling my leg ("That new corporate lawyer, Scales? Dumb as a post. Got him to believe that old saw about electroshock at Rockland State causing a demand peak."). The rest of TK's "rant" is well worth reading.


  1. this is a topic i have a lot of interest in, and a lot of conflicting feelings about. i look forward to hearing what you have to say.

    those commenters, mikewhoever and whoeverelseitwas, sound like most of the people i run into around here.

    nidlwhcy: need we love hipparchy? [yes]
    zxdbrsa: zebras deluxe

  2. sdxai: sudden crossings are inevitable.

    [Warning – rant alert. Proceed at your own risk.]

    One of the engineers at the utility company told me that, back during the 1950s, he noticed a spike in electric demand every Wednesday afternoon. When he inquired about the reason, he found out that this was when inmates at Rockland State were administered electroconvulsive therapy.

    I don’t buy this for a minute. The amount of electricity used for ECT is a tiny fraction of what it takes to run a clothes dryer or electric range. Somebody was either pulling your leg, or repeating an apocryphal myth.

    That being said, I agree with the majority of your post. The largest provider of mental health services in the US, hands down, is the prison system.

    De-institutionalization occurred under the auspices of civil rights, and the civil rights of people in institutions were indeed often violated. But there are powerful disincentives to providing a comprehensive and effective mental health program. For example, I used to work for a county-wide community mental health program that developed a national reputation for the “continuity of care” available to clients. Before long, we were literally being confronted by people sent to us on buses from other states (which we quickly began sending back on those same buses). However, the reputation for services for family also spread among unhappy Medicaid-recipient consumers; it is far more difficult to send back a family who has relocated than a single chronic client who was sent on discharge from the state hospital in Wyoming. That system has degraded considerably since then, and now the vaunted “continuity of care” is largely illusory.

    Interesting, the comments of people like Mike, no? Whence the breakdown in empathic connection, do you think?

    Perception of scarcity encourages increased competition and alienation (not universally, but as a general rule). I find it astounding that we live in a time of such unparalleled opulence, yet people are consistently fearful about losing what they have (as though humanity hadn’t survived millions of years on less), and people are as unhappy as they’ve ever been. Stress is relative, I suppose, to the conditions in which you’re operating. As a culture, to call us spoiled doesn’t really do the problem justice.

    In the case of a Mike, however, I should note that he is deliberately countering feelings of kinship. His verbiage is in reality just the aural manifestation of a mechanism he is employing to deny or undermine feelings of an inconvenient kinship that might threaten his well being because of the obligation it places on him to do something. People in need can be so damned inconvenient!

    On a related note, I was astounded by the seemingly parallel sentiments I did find in community mental health – an astounding proportion of those workers held surprisingly conservative views, given they were all basically social service employees surviving on the teat of the state. Over time, I realized it’s the same problem; it’s very difficult to remain functional in the face of all that need, when the resources at your disposal leave you feeling like you’re fighting forest fires with a squirt gun. The sentiments become a defense against an empathic connection that in that case becomes immobilizing. It is a rare human being that can maintain a helpful degree of openness and connection in the face of all that unending misery and tragedy.

    This is why gifted therapists in the population of community mental health workers are so rare, and also why you realize they belong to an elite group of the finest people on the planet, once you encounter them.

    [Aside: if you want to build a just society, consider the importance of super-ordinate goals (shared goals whose attainment require cooperative action within a group), and the socially devastating impact of social comparisons based on the illusions provided by the idiot box.]

    “Kendra’s law” isn’t going to do a damn thing to address the problem. It does, however, serve the function of making a lot of people feel smug, and allows them to give themselves permission to revert to ignoring the seemingly insurmountable issues of the chronically mentally ill and homelessness (inextricably related). When someone gets pushed in front of a subway car, these same people then feel justified blaming the people manning the dysfunctional, horridly under-funded, and pathetically ineffective mental health system their legislators had so recently been considering for another round of budget cuts.

    We don’t need re-institutionalization. We need commitment laws with teeth, and a mental health system with the resources to provide the level of care necessary for effective treatment. Supervised housing programs and sheltered employment, for example, are fantastic programs that have proven very effective in maintaining people with chronic mental illness at a less restrictive level of care. Assertive community outreach programs are also effective. [We used to joke about the Haldol blow-dart intervention; “Hey, is that a dollar there on the ground?” Thwack!]. There’s no reason that somebody couldn’t have been tracking this man, and keeping in contact with him. If we were to do an economic analysis of the costs of not doing so, the lopsided nature of the savings would cause Libertarians and social conservatives to blanch in disbelief.

    Isn’t that always the way it is with prevention programs? They get tossed because they’re not universally effective, even if they’ve shifted an entire population distribution significantly up the scale of functionality (whatever that is).

    But to be honest, you can look at any functional community mental health program, and if you spend sufficient time there, you’ll find that the entire system is being carried on the backs of about 10-20% of the employees there (if it’s a particularly functional system). Unfortunately, those people who are actually doing the work don’t have the time or energy leftover to lobby their state of federal legislators.

    If you want answers to this vexing problem, you’re going to have to talk to them.

    [Hmmm. I appear to be ranted out. Thanks for waving that red cape in front of my face, Claude – it was good exercise.]

    jvsxhksi: Just ven somebody crosses hellaciousK, sudden invective.

    PS. This would have been a lovely post to cross-post onto Wikifray, if you felt inclined. Just a thought.

  3. PPS. ECT power consumption can be found here.

    TMUFW: too many uninformative words.

  4. Thanks for the props, Claude.

    The difficulty with a rant is that it scares the honest folks away. [oops!]

    I enjoyed your post - we all get taken in by those apocryphal stories sometimes. At my last structured employment, I would respond to every hysterical "chicken-little" email with a quote and link from snopes - and yet, certain people never quite figured out how to check for themselves.

    [snopes didn't have an entry for this one, BTW - I looked there first]

    Social considerations in mental health treatment: if you ever want to provoke a rant from me, this is one of the most reliable ways to do it.

    Thanks Claude.

    nwvrtz: nowhere's very righteous.

    vtben: verboten

  5. zxrulcpx: lord have mercy, maybe the crux of the matter is in rumania somewhere.

    fantastic rant, hellaciousk. thanks.

    wtmvtqsz: what mtv squeeze?