Monday, April 11, 2016

Deinstitutionalization, Sweden edition

From Sweden: A Beggar on Every Corner by Ingrid Carlqvist. I lived in Sweden as a child from 1970-75 and retain much fondness for the estimable Swedes. I keep an eye on them in the news which is why I saw this article. I had not realized Sweden had also deinstitutionalized their mentally ill recently.
Then, suddenly, everything changed. Today, Stockholm, Malmö and Gothenburg are among the cities with the most beggars per-capita in Europe. More and more people feel uneasy about the beggars, who sometimes are even aggressive.

Things started to change in 1995, when a reform of the psychiatric care system led to the closing of psychiatric hospitals and the discharge of patients. People who had been institutionalized for many years were suddenly expected to fend for themselves, with a little help from the government on an outpatient basis. The idea was that it was undignified to keep people locked up in hospitals year after year, but in many instances the alternative turned out to be even worse. Many former psychiatric patients could not manage to cope with daily life outside the hospitals, and ended up as drug-users, homeless and begging on the street.
The article is making the argument that the prevalence of begging, while first surging with deinstitutionalization, had now become dominated by immigrants.

That is a separate issue. It is the deinstitutionalization that interests me.

The US deinstitutionalized the mentally ill in the late 1960s and early 1970s on the belief that new antipsychotic wonder drugs could control mental illness conditions and the promise of half-way facilities to ease transitions and serve as a safety net. The underlying concern was that mental institutions were expensive, subject to barbarism, and were subject to abuse in the sense of committing inconvenient people rather than truly mentally ill people.

The promise has not been delivered on. Medications are much harder to maintain in a non-supervised environment and half-way facilities were prone to the same budget cutting as the institutions. One critic has characterized the deinstitutionalization reforms as simply the transfer of the ill from one institution (hospitals) to another (prison). And indeed, the mentally ill (about 3% of the population) are dramatically over-represented in prison where some 50% of inmates are considered to demonstrate some aspect of mental illness, most commonly depression, followed by bi-polar conditions.

The mentally ill are responsible for some 10% of all murders and ~50% of mass murders.

I knew about the US situation reasonably well. It is interesting to see that the Swedes have experienced similar outcomes. Politicians want to save money. That is understandable. Reformers are legitimately concerned about abuse and institution conditions. Those are verifiable concerns. And the mentally ill have few to advocate for them.

Nobody, as far as I can tell, has struck the right balance between cost, concern, and protection of rights. As long as we are chasing the chimera of racial and gender discrimination (except where there are real demonstrated crimes), we appear not to have the capacity to also deal with what, I suspect, are the much more consequential ethical and social challenges of mental illness and substance abuse. Would that we had the honesty to focus on real problems. The solutions are hard to see but they warrant pursuit.

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