This morning’s Chron features a piece about mentally ill jail inmates in San Francisco.
Those not given treatment and care are spun out to the streets, often ending up in the criminal justice system. Many ultimately go to state prisons. They are the homeless who live and beg on our streets, consumers of street drugs and both victims and perpetrators of street crime.
Police bring disturbed individuals to San Francisco General Hospital’s Psych Emergency Services. In 2007, the hospital had 87 locked ward beds. The 2010 budget would convert them to 22 acute beds and 36 sub-acute beds. Acute wards are locked wards with around-the-clock supervision, and provide an alternative to jail for the most severely ill persons, generally those with schizophrenia or bipolar illnesses, brought in by police under a 14-day hold permitted under state law and reimbursed by Medicare. Sub-acute wards are for those patients who are medically stabilized. For the seriously ill, an acute ward is the only alternative to jail.
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This has been an ongoing issue ever since deinstitutionalization in the 1960s, and, of course, we here in California are the inheritors of the rest of the country's homeless. I wonder if it would be easier and cheaper to intervene earlier (as in, before someone has decompensated living on the street and taking drugs far enough that they wind up in a criminal court), but I guess that raises all the old civil liberties and ethical problems we had before that led to deinstitutionalization (see, e.g.: "One Flew Over the Cuckoo's Nest", the work of Foucault, R.D. Laing, and Thomas Szasz). Of course, deinstitutionalization was supposed to be accompanied by a big push for "community mental health", which would presumably have stemmed some of the problem…
One of the sad truisms of correctional policy is that hindsight is always 20/20. We're now bemoaning the big decarcerations and deinstitutionalizations of the 1980s, which 1960s writers like Szasz and Kesey would see as a welcome development. But as you say, Tom, the devil's in the details. Had there actually been a good infrastructure of community mental health this would not be such a problem.
Well, for better or worse and whatever the political fallout, it looks like we will have a new healthcare bill that, for one thing, will mandate covering non-dependent children to age 26. Most people who are going to have psychiatric or substance abuse problems will start showing signs before they are 26. It might provide an avenue for some sort of preventative care that would cut costs in the long run. It's possible, at least.
That would be a very good thing, provided that people still seek the sort of treatment they need.