American states wrestle with how to treat severe mental illness

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WHEN AISLINN BIRD is not treating patients at her health clinic in downtown Oakland, she goes to see them where they live: in homeless encampments. Many of them sleep in tents under train tracks or highway overpasses. “If a big truck comes by or if the…train goes by, I have to stop the interview because then I can’t hear my patients,” she says. “It’s hard to create a therapeutic environment out here.” Dr Bird is part of a growing group of psychiatrists practising street medicine. Her teams frequent encampments around Oakland, offering homeless people everything from regular check-ups to treatment for mental illness and drug addiction.

More than a quarter of homeless Californians recently surveyed by the University of California in San Francisco said they had been hospitalised for mental illness. Two-thirds said they were currently struggling with a mental-health condition, ranging from anxiety to hallucinations. One third of respondents said they regularly use methamphetamine, which can cause psychosis akin to schizophrenia. This hazardous combination of drug use, mental illness and the physical hardship of sleeping rough has increased homeless deaths in big cities across the country. Some 2,200 homeless people died in LA County in 2021, an increase of 70% from 2019. The daily tragedies playing out on America’s streets are also changing the politics of homelessness in liberal states—and nowhere more than in California.

A slate of reforms signed into law last week in California is meant to tackle this problem. Standing at a podium that read “Treatment not tents”, California’s Democratic governor, Gavin Newsom, called the bills “a paradigm shift” and a message to voters that policymakers intend to clean up the streets. California’s new laws also exemplify two broad shifts in mental health care in America: the building of more beds for patients suffering from mental illness and drug addiction, and an expansion of involuntary treatment.

First, consider the billions that American states are pouring into facilities to treat and house mentally ill people. One bill Mr Newsom signed into law will put a $6.4bn bond measure to help build more than 10,000 treatment beds and housing units on the ballot for Californians to vote on in March. When asked what happens if Californians do not go for it, Mr Newsom told The Economist that he cannot imagine it failing. His message to voters is “Vote no if you believe in the status quo.” Kathy Hochul, the governor of New York, set aside $1bn in her 2024 budget for psychiatric hospital beds and longer-term housing. The Texas legislature allocated some $2bn over the next two years to build and maintain mental-health hospitals.

It is rare that Texas and California agree. But three things have raised the profile of mental health among Americans of all stripes: the anxiety and isolation many felt during the covid-19 pandemic; the destruction opioids have wrought; and the visible suffering of unsheltered homeless people with mental illness. The need is also immense. The number of psychiatric beds per person in America is low compared with much of the OECD, a club mostly of rich countries. America has less than half as many beds per person as France.

Mr Newsom describes his overhaul as fulfilling a promise made by then-governor Ronald Reagan in the 1960s to replace overcrowded, often abusive state-run institutions with smaller, local facilities. Yet after Reagan, rightly, closed the asylums and expanded patients’ rights, he failed to fund community care. When Reagan became president, the country followed California down this road. But blaming Reagan ignores the nearly 50 years of inaction since he left Sacramento, the state capital. “The failure of successive state governments to uphold the community funding promise is one of the main reasons people are suffering so badly today,” says Darrell Steinberg, the current mayor of Sacramento and an advocate for reform.

The other striking feature in California is the expansion of involuntary treatment. Mr Newsom signed a law on October 10th, SB 43, that loosens the criteria for people to be placed in a mental-health conservatorship, in which a person appointed by the state directs their care. Its passage follows the creation last year of CARE Court, a programme that allows health workers, police and family members to enroll people with psychosis in court-mandated treatment. Alex Barnard of New York University, who is tracking state laws that expand forced treatment, finds that reforms are clustered in coastal Democratic states such as California, Oregon and Washington that are reckoning with very visible displays of mental illness among homeless people.

Growing anger from voters helps explain why Democratic politicians in liberal states are grasping for policies usually associated with law-and-order Republicans. Civil liberties and disability rights groups are fighting the political tide. They argue that SB 43 and CARE Court infringe on patients’ freedoms and bodily autonomy. Disability Rights California, a non-profit, worries that the laws will unfairly target black Californians, who are disproportionately represented among the state’s homeless population, and will traumatise people. They have a point. The evidence for the efficacy of involuntary treatment is mixed.

“They’re simply wrong,” Mr Newsom says of the civil-rights groups. “Look what’s happening on the streets. It’s night of the living dead in the Tenderloin in San Francisco…and people are dying.” He suggests that the extreme libertarianism displayed on the streets is an embarrassing abdication of state responsibility. To the governor and his allies, these new laws represent a move towards the centre and a recommitment to a social contract. To his opponents, they reek of state overreach.

Even while trumpeting the new laws, policymakers stress that involuntary treatment should remain a last resort. Their hope is that the expansion of beds makes it more likely that people suffering from mental illness get the level of care they need, and avoid languishing in jail or hospital for want of a safe alternative.

The neglect that California showed its most vulnerable when the institutions were closed is a prime example of good intentions gone wrong. Decades later, Mr Newsom hopes California can provide America with a model for how to fix things. He refers to the rest of his term as “the great implementation”. His focus on beds echoes those who spend the most time among homeless and mentally ill Californians. When asked what would make her job easier, Dr Bird laughs. Without any hesitation, she answers: “More housing.”

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