State Hospitals for Severely Mentally Ill Homeless Should Be Revived
Abstract
Four thousand severely mentally ill people and people with substance use disorder (SUD) live on the streets and in homeless camps in San Francisco—just one major American city. From the 1970s, as state mental hospitals closed with the false promise of “saving taxpayers money” and the promise of creating community-based resources, the number of homeless mentally ill people rose at the same tempo. Community care and short-stay city ward care are unavailable or Bandaid care. Why isn’t anybody talking about reviving state hospitals?
This opposition likely stems from three myths:
Myth 1: Mental hospitals take away freedom. Aside from involuntary commitments for people who are a danger to themselves or others, loss of freedom isn’t necessary. A clinically informed approach respects patients’ wishes to leave the hospital. Staff and hearing judges can sometimes mistakenly overextend stays, but a hospital mission favoring and facilitating patients coming and going between their communities and their regional hospital can mitigate mistakes, even improve clinical outcomes.
This model views hospitalization, stabilization, discharge, decompensation, and rehospitalization as a cyclic part of illness and a treatment opportunity for patients to learn the extent to which they can care for themselves, just as people with SUDs may need many relapses to accept sobriety.
Some mentally ill homeless will never be able to care for themselves because of chronic hallucinations, delusions, incoherent speech, confusion, withdrawal, apathy, and agitation—often little touched by medications. People with SUDs often progress to physical disability and dementia.
Ultimately, many patients will choose to live in the community that a good state hospital can provide and stop cycling back and forth between the streets and hospital. This community includes safe, fenced landscaped grounds; open wards; dependability; vocational rehabilitation; education; psychotherapy; psychotropic medications; and medical care.
Myth 2: State mental hospitals are snake pits. I have worked at state hospitals. They all had caring staffs. The myth derives from bestsellers of the 1900s that dramatically fictionalized actual neglect and cruelty that today’s safeguards can recognize. The real snake pits today are the city jails where people with serious mental illness are hospitalized after minor crimes because there is nowhere else for them to go. Treatment in jails is sham treatment.
Myth 3: State mental hospitals are too expensive. San Francisco haplessly cares for its homeless people who are ill at a cost of $360 million a year. This doesn’t include the cost to the city from residents and visitors abandoning its center. If 40 million Californians paid an average of $100 more in taxes, it would generate $4 billion, sufficient for residential care for all unsheltered people with serious mental illness in all of California. How does this compare with the cost of managing our sadness and guilt at witnessing people suffering on our streets and turning away from them? ■
