Scott writes in My IRB nightmare about how his colleague took people freedom away and justified it with tests that aren’t validated for the purpose of diagnosis and that have a warning THIS IS JUST A SCREENING TEST IT IS NOT INTENDED FOR DIAGNOSIS.
This can only happen because there’s very little public accountability and suggests that a lot of abuse of power is going on. While the US has a lower psychiatric hospitals bed count then many other OECD countries, there are still ~80,000 people in those institutions. A lot of them effective have very little rights and have to endure medical procedures without them consenting such as taking various drugs.
Mental health people seem to me like they should be classified as a marginalized group by the ideals of modern left. On the other hand the modern left put very little attention on fighting for the their rights as evidenced by Scott’s colleague getting away with major abuse of power.
Why is the state of affairs like it is? Why don’t they get more attention?
Mental hospitals of the type I worked at when writing that post only keep patients for a few days, maybe a few weeks at tops. This means there’s no long-term constituency for fighting them, and the cost of errors is (comparatively) low.
The procedures for these hospitals would be hard to change. It’s hard to have a law like “you need a judge to approve sending someone to a mental hospital”, because maybe someone’s trying to kill themselves right now and the soonest a judge has an opening is three days from now. So the standard rule is “use your own judgment and a judge will review it in a week or two”, but most psychiatric cases resolve before then and never have to see a judge. In theory patients can sue doctors if they think they were being held improperly, but they almost never get around to doing this and when they do they almost never win, for a combination of “they’re usually wrong about the law and sometimes obviously insane” and “judges are biased towards doctors because they seem to know what they’re talking about”. Also, the law just got done instituting extremely severe and unpredictable punishments to any doctor who doesn’t commit someone to a mental hospital and then that person does anything bad ever, and the law has kindly decided not to be extremely severe on both sides.
There are other mental hospitals that keep people for months or years, but these do have very strict requirements for getting someone into them and are much more careful.
Hard in the sense that there’s a lot of lobbying power behind the legacy system but that’s not for lack of alternatives.
Prediction-based medicine where one doctor makes predictions about what’s likely to happen when the patient doesn’t get hospitalized and what happens with them when they are hospitalized and then letting another doctor make the decision to hospitalize or not hospitalize isn’t very hard.
Then you fire those people who make bad predictions because they are unqualified to do their job.
I think it’s perfectly fine to require the opinion of two doctors to take away the freedom as taking freedom away is a major move and I think it’s reasonable to require the ability to make accurate predictions about harm to justify taking away someones freedom.
People, by default, do not care very much about the suffering of the powerless. This is a very general pattern: De facto torture of the old and dying (Who by Very Slow Decay), Animal in factory farms, prisoners in solitary, Scott’s rant about school being child prison, etc.
There is no real need to explain a specific example of a very general trend. In fact it is the opposite that needs explanation. We actually have made progress in various ways (for example slavery is greatly reduced, though the USA still has prisoner slaves). But compassion toward the powerless is a deviation from the default. We need to fight for it. The fight has not been won in the USA.
There are a lot of people who care about animals in factory farms, a lot of grant money and many organizations. Prison reform is similar. Both causes are clearly part of the modern left coalition.
There aren’t similarly powerful organizations that care about the rights of patients in psychiatric hospitals.
In the particular case of factory farming, there’s a costly-but-simple solution: stop doing it. The animals’ lives are not worth having, so we stop creating them. For some subset of patients in mental hospitals, who can’t create good lives for themselves on their own and a further subset of whom are dangerous to others, it’s really not clear what we should be doing. Just letting people go created a bunch of negative externalities and it’s questionable whether the patients themselves were better off. Really amazingly good care, when we know how to do it, which is not always, is excruciatingly expensive. So even if someone cares about this issue a lot, it’s really not obvious what they should do or ask for.
EDIT: I finished rereading the SSC post I linked to and apparently there just is a better thing, outpatient commitment, and we should get right on that.
From my Nordic perspective being ok to standby when other groups fail to powergrab decent conditions seems like an outlier.
To be at first glance but not actually contrarian: we are not putting enough people (who should be there) into psychiatric hospitals. This is not exclusionary of the idea that people are winding up in mental asylum who should not be there. Rather, the two are complimentary: poor diagnostics and lack of accountability, as well as limited resources, ensure that there are likely large amounts of both “should not be institutionalized but are institutionalized” and “should be institonalized but are not.”
I do not live in the United States, but in a similar Western democracy and worked for a year in a health bureaucracy that contracted psychiatrists to work in mental hospitals. The doctors were under great pressure, due to lack of funding, to release people as soon as possible, whether or not mental health support was available in the community they would be returning to (in most cases, this meant “the street/homeless shelter”). As a result, relapse/readmission was near constant.
As to what prevents them from becoming a constituency for the modern left—even when many of them are ethnic minorities—the reasons identified below are cogent, and I would add, to judge from the people we dealt with in my job, the mentally ill are unpleasant/unsettling to deal with. I know many people who will talk about their grad school depressions as a major mental illness, but they have nothing on the cases the psychiatrists I worked with handled. Serial arsonists, people who habitually ate glass and metal, others convinced that all indigenous people were possessed by the devils and lashed out at them at every opportunity.
The mentally ill are also often the cause of many other (politically preferred) social problems. Recently, in my city, there were a string of verbal assaults and physical intimidations of Muslim women at transit stations. After widespread condemnation of these attacks and community groups talking about the need to “raise awareness” , with an implicit assumption that the actors were many, the police figured out the attacks were the work of two mentally ill men with long histories of on again/off again institutionalization. The attacks stopped and the issue disappeares from the news. To be blunt, no one gains anything from directing attention at the mentally ill.
Mental health in general in the US (and around the world) is poorly understood. Pop-psychology spreads myth, misinformation, and disinformation and Big Pharma preaches advancements in medication over advancements in therapy and counseling models. Money talks, and no one can argue with Big Pharma in this arena. Unless you are a professional in the field of mental health or a client or friend or family member of one, most people don’t care to know how the sausage gets made in terms of keeping ‘mentally ill’ people under control, and even fewer people care whether keeping them under control is an actual solution to the very real problems they face.
I’ve been living in a mental health institution for the last 2 years, and have been in the public mental health system practically from birth. We’re deemed scapegoats of the society, like criminals and often treated just as bad or worse. This society only knows itself by creating false dichotomies: classifying ‘these people’ as mentally ill, and ‘these people’ as not, based on a somewhat circular logic which allows for the unfair division of resources and diversion of those resources to those who are deemed ‘able’ to use them.
The way the authorities tell the difference between the 2 groups is way too often archaic and systemically discriminatory, and mental health has become so enmeshed with the criminal justice system so as to almost become indistinguishable from it at the Public level. Society needs people on the bottom so that others can be on top. Wish it were otherwise.
In some way we treat mental patients even worse then prisoners. Prisoners don’t get medicated against there will.
Being inside the system I expect you to understand it well. Given the suggestion in other comments that the problem might be due to a lack of obvious policy proposals it would be valuable to have easy to understand proposals. Do you have one? I think it would be valuable to have it spelled out.
Short answer:
Policy regarding research needs to be changed before making policy changes in distribution of care will make much of a difference overall IMHO. There is already a ton of infrastructure—human, physical and financial—in place to offer the services that are available; many types of policy changes to the offerings of care itself can be made. However there are serious areas of need not being met, and it still seems regardless of who’s in power at this point in time, strides in this regard are unlikely to be made without serious reconsideration of societies approach to it’s priorities.
Longer answer:
One of the main reasons has little to do with the Mental Health Care system per se, but rather how it is integrated (or not) into the broader society. The concept of Community Mental Health Care sounds good in theory, but in practice it still focuses primarily on individuals with ‘mental disorders’ as being the problem instead of understanding and making changes to how the community (or society) functions when it fails these people.
In my opinion Mental Disorder is a problem caused by something like a misaligned community and/or society, and people with mental health disorders are victims of neglectful or harmful aspects of their Communities or Society. Treating their symptoms does nothing to fix the underlying systemic issues causing the symptoms or problems in the first place. Without knowing where or how to make the changes, the problems are just shifted from one part of society to another.
Another aspect of this issue involves the distribution of goods and services both in this country and around the world, as Public Health Care becomes a reinvigorated topic of consideration domestically. Consider the fact there are serious differences between Public and Private Mental Health Care. Should Public Mental Health Care be as good as Private Mental Health Care even though it’s clients are poor and the government is paying for it? Or should Public care be less effective because it is provided ″for free” by the government? Or is it possible like many things in this country, we pay way more for goods and services than other countries do?
Pharmaceuticals are an easily accessible case in point. For example: If we can afford to give half a billion doses of COVID vaccine to poor countries, why can’t I as an American Citizen in the Public System, get the type of mental health care I need? The money to buy those doses going to other countries could fund the type of therapy I need to heal my severe PTSD, but instead I don’t receive appropriate care because the money isn’t available. Why is it the needs of poor people in other countries are often times prioritized over the needs of poor Americans?
This is the type of political reality many people with ill intentions latch onto, and weaponize in political discussions. Which makes having rational conversations about issues like that difficult and tends to have the effect of focusing on that one aspect to the detriment of the rest of the conversation that should be taking place. It can become a ‘can’t see the forest for the tree’ problem. So many people with good intentions avoid the conversations altogether in the belief it’s a Pandoras Box.
That doesn’t change the fact that there are a lot of conversations not happening at high levels I’m sure, that should, because they involve what would be considered unpopular opinions. These topics are ignored and backgrounded because they don’t test well with the audience, but this doesn’t change the fact that they are real issues. It just means it’s taboo to talk about them or attempt to find solutions to the problems they are associated with. Politics is the mind killer.
The fact is the Mental Health Care Culture is in crisis because it is overloaded and under-equipped to deal with the overwhelming nature of the issues.
More workers won’t make a significant difference if they aren’t trained well and good training is hard to get because many of the old models don’t work like we were told they do; this is where too often things like over reliance on medication leaves clients/patients without access to any type of effective counseling, therapy or support. While medication can improve counseling and therapy, it is not a replacement for counseling and/or therapy, yet in an overwhelming number of cases this is the reality. The thinking goes along the lines “Something is better than nothing.” I’ve often found this results later on in “Too little too late.”
Some old models work but need updated or potentially rolled back; this is where I believe alcohol and drug addiction treatment needs to be separated from mental health care treatment, as they are both 2 very different treatment modalities (or should be) yet in the name of government ‘efficiency’ they were collapsed into one department within many state governments a few decades back. What used to be treated as 2 separate issues by 2 different departments with 2 different treatment modalities became 1 badly integrated governmental department with a ‘1 size fits all’ approach to whatever ails you. Add in the further unskillfull integration of the Criminal Justice and Public Legal Systems into this community which is in constant crisis, and what we have is a horrific tragedy which keeps unfolding over time which no one takes responsibility for or is able to effectively influence in a positive way.
Additionally, some models of treatment need to be dropped entirely while others need to be created to repair the damage done by the models which did more harm than good. Gay conversion therapy is an example of what I’m talking about here; programs like these functioned with government oversight and federal funding and the amount of damage caused was and is tremendous. Treating the victims of treatment like this is a specialty service that didn’t exist until there was a recognized need for it.
There are still programs in this vein that need to be terminated and replaced with effective treatments, and there are many victims who still suffer because their suffering isn’t yet recognized. Quite often these are men and boys, and in a Schizophrenic society like the US, society can’t figure out whether they are victims or perpetrators. If we try to consider them both, and even think about affording them the care and support they need to heal from their victimization, we’re afraid our heads will explode because we’re also trying to punish them for being perpetrators at the same time. Our system is a punitive system, and is the major underlying flaw of Western Tradition from my current perspective. Still trying to write about this.
Given the pace of change across the board, from changing peoples minds, to changing their habits, to changing the physical environment they inhabit, making bad calls in policy changes has the result of wasting massive amounts of resources and causing massive amounts of suffering. I won’t go into why now, but, comprehensive re-examination of the research done in the decades leading up to our current time needs to be done using better tools and methods with our newer understandings before things will change much for the better. I’m not offering quick solutions, just more comprehensive and potentially effective ones.
This process would be complicated and multi layered, but necessary to re-frame and re-integrate new understandings into older but correct models and scientific frameworks, and to create new frameworks based on better understanding of the consequences of the mistakes of the past. Outdated, polluted and biased data can lead to polluted information, polluted information can lead to polluted knowledge bases, these in turn lead to polluted decisions regarding policy changes which muddy the waters instead of clearing them up.
We’re at a cross roads in Western Society; we are laying a new technologically advanced foundation for the future on a shaky foundation of pre-digital knowledge, wisdom and understanding. I’m suggesting we shore up the foundations of Western Society culturally before we attempt to keep building upwards. The Psycho-Socio-Econo-Tectonic plate system of the world wide cultural subconscious is full of faults, and the if we don’t understand them well, they’ll be our downfall whether we do it ourselves or engineer AGI to do it for us intentionally or unintentionally.
This is why my money is on better research being the key. Getting politicians to pay attention to these concerns is another matter, and as we’ve seen with the public response to the COVID Pandemic, even when the research is done, and the majority of the government is on board, disseminating and assimilating good solutions into society in a positive way is often a huge struggle. This issue of Cultural Lag is a constant thread that runs throughout any type of positive change in society. Which is why I’m still working on a model of Social Physics.
Developed nations can’t afford not to give a lot of COVID vaccine doses to poor countries. Not giving poor countries vaccines means giving COVID-19 more opportunity to mutate and cause a new wave in developed countries.
The cost of a new wave in a country like the US is so high that it makes a lot of sense to prevent it buy giving poor countries vaccines.
Americans whether poor or rich need poor people in developed countries to take vaccines. Pandemic prevention doesn’t work if you don’t think globally and fight viruses where ever they are. Fighting viruses while they are in foreign lands with vaccines is similar to send the military to foreign lands to prevent people from attacking your homeland and generally there’s much more money wasted in military for preventing foreign threads then in public health.
In general the US spends a lot less on foreign aid that most people assume and a lot of the money it does spend gets spend for geopolitical aims such as paying off the Egyptian millitary for accepting Israel as a state.
Josh is unable to post at this point, but here’s his response:
Short answer:
I’m in agreement with the intention of this thinking 100%; being a responsible world leader includes taking responsibility for helping poorer countries in instances like this. I disagree with how those intentions are realized at times however. America has limited resources despite acting like we don’t. When we still struggle as much as we do with poverty, hunger, and poor health care domestically, I believe it’s ethical to question spending on health initiatives in other countries.
There’s some sort of “out of sight, out of [their] minds” pun here.
That aside, isn’t this the actual purpose of mental institutions? Like the attics of previous generations, they are where we stow people we prefer not to think about. And you have to admit they do that job very well indeed.
The question is why does the attic work so well. Why does no one talk about the attic?
An attic runner has likely a very personal connection to the detainee.
They also have better information control and likely include a lot more persuasion in elicting cooperation from the detainee. It is easier to contain a person if they think it would be shameful for them to run loose.
I remember when there was a lot of attention being given to Amanda Knox here on LW. Someone asked a similar question as you...something along the lines of “Why aren’t more people up in arms about this?”
The answer for me at that time was that I have a certain number of Attention Dollars to spend. People are wrongfully imprisoned all over the world every day. New video cards are too expensive. Kids are being tortured. McDonald’s stopped serving salads during the pandemic. There’s all sorts of things to spend my AD’s on.
Attention to causes and injustices costs AD and there is a high transaction cost to switching which injustices are important to me. I hypothesize that the complex system that is the-attention-of-public-discourse suffers from the same. There’s only so much capacity for giving attention to different causes, and switching those causes carries a high price.
That’s not to say Cause X is wrong or less important, only that I (and, hypothetically, public discourse) can only focus on a limited number of things, there’s costs to switching attention, and other things beat Cause X in the race to capture attention.
Different things probably come to the forefront through quirks of zeitgeist, personal relevance, effective messaging, attentional resources available at the time, and a dozen other subtle and not-so-subtle factors.
Of course, this doesn’t really answer your question (and here I am submitting it as an answer)! It only pushes the “why’s” to another level. Why can public discourse only focus on a limited number of things? Why, exactly, is it currently focusing on the things it is? Why are the transaction costs to switching attention high? I suspect that the answers are very complicated and unknown.
There is an economy of public attention. The amount of noise is high, and information asymmetries abound. If you think Cause X is not getting the amount of attention it should then you should work on lowering the information asymmetries and noise level...and recognize that if Cause X gets more attention it’ll mean Cause Y that everyone is currently paying attention to will get less attention. (At least if my model holds.)
Also, you say ”...suggests that a lot of abuse of power is going on.” I think that this conclusion depends a lot on your priors. One type of person is going to see a bad seed when they see this story, another type of person is going to see a corrupt institution. This feeds into this hypothetical economy of public attention.
How confident are you in this being the main reason and not other suggested reasons provided in this thread?
The fact that the story exists and there doesn’t seem to be a follow up and some agency felt it’s responsible for fixing the issue is part of the story.
You can argue that something is a bad apple when the bad apple gets removed by the owner when attention comes to it.
My question isn’t about the number of people who are up in arms but about understanding the makeup of the modern left. In this thread you find people asserting that psychatristic patient are in a similar reference class as child abuse, animal suffering in factory farming and prisoners being mistreated. The fact that it gets a lot less attention then other topics in that reference class is what the question is about.
I would answer that systemic issues are more important then the fate of individual people. To the extend that the Amanda Knox case is about the Italian Justice system being bad and in need of reform, that’s largely a topic for Italians.
I propose that this explanation is orthogonal to the other reasons provided in this thread. In other words, I propose that this explanation holds true whether or not any of the other explanations are also true and that no matter how true any of the other proposed explanations are, it does not diminish the explanatory power of this explanation.
I would say all other proposed explanations are just variations on:
For example, let’s say that when deluks917 says people do do not care very much about the suffering of the powerless that they’ve made an accurate description. That feeds into the attentional price people are willing to pay in my proposed model.
It’s too early in my ruminations of applying this model to “public discourse” or however you want to say system-composed-of-people for me to say how confident I am in it’s applicability. I’m somewhat confident that it explains individual people’s attention at least some large portion of the time.
If my proposed model is true, then the modern left is just a subset of all public discourse and subject to the same attentional economy.
Yeah, I was trying to get to the fact that my answer is possibly more meta than the answer you’re looking for when I joked about me not answering your question with my answer. However, I think my proposed model doesn’t care about reference classes as you seem to be saying. Attention is attention, and everything that would fit in the reference class of injustices against marginalized peoples has to pay it’s attention dollars just as each reference class has to pay.
Sure. I wasn’t saying that Amanda Knox was or was not as important as the systemic issues. I was saying that the reason Amanda Knox didn’t get more attention is (potentially) the same reason that the mental health issues you’re asking about don’t get more attention. People and systems made of people only have so much attention to go around.
More concretely, if my proposed model is accurate, then one explanation of why this issue is not more central to the modern left is that the transactional costs of entering the left’s zeitgeist have so far not been paid. There’s lots of injustices and the attentional resources are currently spent on other things.
Without having a good idea whether the costs are equivalent to ~10,000 dollars in effort or ~100,000,000 dollars I don’t think that explanation contains much information.
There are some issues where it’s very cheap to put them into public attention and others where it isn’t.
If I would ask “Why don’t have have interstellar travel?” answering “Because the costs of developing interstellar travel haven’t been paid” might be a correct answer but at the same time completely useless for understaning the challenges of developing interstallar travel.
Thought 1: Stars don’t love cake
If you were to ask which star loves cake the most, and someone responded with an explanation about the differences between inanimate objects and cake-eating entities, that someone didn’t provide the type of answer you were looking for.
Why doesn’t the modern left seem to care so much about patients in mental institutions? Given the resource constraints model I’m pondering: Maybe you’ve misread how prevalent or important the issue is. Maybe you’re asking the wrong question. Maybe the modern left has less resources available than you thought.
Thought 2: Actually, it does answer your question
I wouldn’t be surprised if “the transaction costs have not been paid” is the answer.
ChristianKi: “Dustin, how come you didn’t eat lunch out with us today?”
Dustin: “I didn’t have any money in my wallet.”
I think the money-in-wallet answer is a useful, valid, and expected answer. However, there are other answers. Cash flow and accounting. Pay rates for people talking on the internet. Childhood causes of future careers and decision making. Government policies affecting food pricing. However, the proximate cause, and often the most useful answer, is “I didn’t have any money in my wallet.”
Thought 3: It’s not so obvious and that has consequences
The triple constraint model “Good, fast, cheap. Choose two.” is bandied about because it’s not second nature for some (many?) (most?) to keep in mind that there are resources constraints. This is often or usually with concrete physical work in the real world, not some nebulous concept like attentional resources!
I think it’s likely that the idea that there are costs to building physical objects like warp drives is more innate to people than the idea that there are limited funds available to pay for the things we can care about.
An entity that has acknowledged that there are attentional constraints will behave differently from one that has not. Thus, you can gain insight into the entity by observing it’s behavior. For example, if you think patients in mental institutions is salient thing for modern left given what the modern left seems to care about, and the modern left isn’t paying as much attention to it, then perhaps you’ve gained insight into the fact that the modern left needs to learn about attentional resources.
Thought 4: Warp drives
NASA didn’t take the project management triangle to heart during the course of space shuttle development.
By observing this, we learn lessons about the challenges we’ll face during interstellar travel plans.
...
As I said, my answer doesn’t exactly map onto your question, but I think it’s close.
I see a difference in that burocrazy is not allowed to interfere with peoples treatment but it is allowed to interfere research.
Given that SCREENING ONLY labels are not followed having more of those guidelines would not alter patients care. By making such requirements it might give raise to an illusion or image that the care has certain properties.
The doctors ar effectively operating under the collar of science without actually applying science. With greater adherence we would either get pushpack to follow less scientific advice to the level where it is practical or treatment would grind to a halt.
With some other processss we don’t only care that they are possible, we want them to be smooth. Having high rigour and high practicability is a big value conflict. Most conditions are mysterious to most people so being able to justifiably know is more concretely valuable. This would predict that if general awareness of the existence of mental health conditions increases then efficiency of care could start to outshine rigour.
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