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Why do patients in mental institutions get so little attention in the public discourse?

by ChristianKl1 min read12th Jun 202127 comments

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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? 

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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.

The procedures for these hospitals would be hard to change. 

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 unqualifi... (read more)

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.

6Elizabeth1moIn 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 [https://slatestarcodex.com/2016/03/31/book-review-my-brother-ron/] 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.

4Josh Smith-Brennan1moShort 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
4ChristianKl1moDeveloped 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.
0Symbol Away1moJosh 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?

2Slider1moAn 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?

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. 

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. 

I remember when there was a lot of

... (read more)
2Dustin1moI 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 is
2ChristianKl1moWithout 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.
2Dustin1moThought 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

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.

We occupy a low strata in society and we are afforded the consideration commensurate with that.

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It's just a general pattern of overlooking certain kinds of terrible suffering that is not very visible. My go-to example is that, even by the most conservative estimates, at least 1% of children go through severe physical, emotional and sexual abuse growing up, which means that, if you live in the city, there is a high chance that there a girl being raped by her brother/uncle/father within a mile of you right now and no one would hear about it or pay attention, until it's too late. A decade or two or three down the road she will end up in a psych ward with incurable CPTSD manifesting as a host of personality disorders, only to be marginalized and often abused and neglected there, as well. 

Omelas was so much better, even for the one suffering child, compared to our society. At least everyone there knew about the suffering child, and it was not completely in vain. And there is nowhere to walk away, it's no better anywhere else.

There's an enormous amount of work into fighting child-hood abuse in the last decades. We criminalized hitting children and have see-something-say-something as a paradigm for whole of of different policies. While those policies don't bring childhood abuse to zero society tries very hard. The LGBT community that used to ally with pedophiles stopped doing so and people who are advocating for the marginalized group of pedophiles are now clearly out of the coalition because caring about children not being abused is central to the modern left. 

incurable 

That's such a strange word. The word incurable is a license to avoid accountability for not curing illnesses. It's a class of illnesses for which psychiatric hospitals lack the skills to cure them at this point in time. It's a feature of the psychatristic community and not an inherent feature of the disease. 

As the Schizophrenia Research Project suggests it's plausible that for a good portion of them the drugs that the psychologists give them inhibits the natural healing process. 

A cynical guess is that in politics you only fight for rights of people when it is profitable -- if you expect that in turn they become your voters. You care about minorities either if they are large enough, or if other groups feel like they are in the same reference class.

Apparently, psychiatric patients are not numerous enough (to vote for you in return for your help), and other groups of people do not identify with them enough (to vote for you in return for your help to them).

Other possibilities that spring to mind are:

  • The difficulty of them becoming your voters
  • The opportunity has been overlooked. (The market is not all knowing.)
  • It conflicts with other interests already secured.

I think "why doesn't it get more attention" is the wrong question to ask.  "What's the better solution" and "what should I do to improve things" are likely to get more traction here.

I think "why doesn't it get more attention" is the wrong question to ask.  "What's the better solution" and "what should I do to improve things" are likely to get more traction here.

This looks to me like it comes from a mindkilled point of view, that discount the value of knowledge. 

"How should we solve X?" is a different question from "Why is the current political coalition the way it is?"

The first question is about solving a political cause. The second question is about understanding. 

In the model that deluks917 proposes animal rights, prisoners and psychatric patients should have similar amount of backing for their cause. In our world that's not the case. There's something wrong in the model. The rational way to deal with unexplained derivations from models is to try to understand them to update the model. 

The fact that people like shminux and deluks917 mistakenly put it in the same reference class as problems that the modern left cares about is interesting and suggest a broken model.

This looks to me like it comes from a mindkilled point of view

Quite possibly.  I did and do make the inference that the post was targeted at the question as a political issue (with the intent to change it, not as an academic exploration).  That form of question is so commonly used that way, that it requires disclaimers and multiple examples for me to even consider that it might be otherwise.

I also skipped a step, in failing to state that I do not actually know whether it's a problem, nor if so, whether it's significant enough to put much attention on.  Compared to general human poverty and wasted potential, the short lifespans of humans, and the significant existential risks that face intelligent life in this corner of the universe, I think it may be correct to spend less effort on specific marginal cases.