Sons, Daughters, and Sidewalk Psychotics: Mental Illness and Homelessness in Los Angeles, by Neil Gong (University of Chicago Press, 328 pp., $30)
In his new book Sons, Daughters, and Sidewalk Psychotics, sociologist Neil Gong provides a class-based analysis of mental-health care. His focus is outpatient programs for the seriously mentally ill in Los Angeles. Gong examines, on the one hand, public programs for schizophrenics without resources and, on the other, private programs that serve schizophrenics with resources. Many sociologists would organize an analysis like that to denounce capitalism, but Gong is not a class warrior. As he sees it, though being rich is better when it comes to serious mental illness, money can’t buy recovery. Mental-health programs for the rich and poor differ more notably with respect to their goals than their outcomes. Middle-class families with schizophrenic relatives find themselves in the most awkward spot, for apparently no programs cater specifically to their needs and capacities.
Clients of the public programs that Gong observes are formerly chronically homeless individuals living in subsidized apartments on the Housing First model—the dominant public-policy approach to homelessness, which holds that the only solution is government-provided permanent housing, with no preconditions (sobriety, work, etc.) for recipients. These units are paired with “wraparound services” delivered via “Assertive Community Treatment.” ACT teams are thought to provide an almost inpatient-level of care in a community setting; the approach is sometimes described as a “hospital without walls.”
Gong characterizes ACT as neither intensive nor particularly clinical. The providers featured in his book handle friction with landlords, promote compliance with probation, help handle clients’ furniture during move-ins, and generally convey “information for surviving as a poor mental patient.” Their clients, though housed for the moment at least, still have profound social needs requiring all manner of social work. Success is defined negatively, mainly in terms of avoiding homelessness and jail.
The public programs that Gong observes aim at “tolerant containment.” That’s a provocative term for anyone familiar with the history of homelessness. As Gong notes, L.A., back in the 1970s, made a concerted effort to preserve its slum housing in the notorious Skid Row district that neighbors downtown. That way, homelessness-related disorder could be limited to within Skid Row’s borders. Skid Row is still there, but over the decades, most Angelenos lost faith in containment as they watched homelessness spread. Gong, however, argues that containment is still alive and well. Rather than being confined to a certain neighborhood, the mentally ill homeless are individually contained within thousands of independent apartments.
Proponents typically describe Housing First and ACT as designed to advance treatment and human flourishing based on a profound respect for individual autonomy. Gong argues instead that these programs are in the social-control business.
The private outpatient program Gong profiles costs, at the base rate, $5,000 per month. It defines success more positively than the public programs. Private programs help the seriously mentally ill pursue lives of meaning and respectability; they are more functionally clinical. They take psychiatric diagnosis seriously because they provide access (at an added cost) to targeted therapies for conditions such as obsessive-compulsive disorder, borderline personality disorder, eating disorders, and trauma. In the public programs Gong examines, by contrast, settling on a diagnosis is a bureaucratic exercise pursued mainly to help someone qualify for benefits.
But clients with resources still often struggle—sometimes because of, rather than despite, those resources. They spend money on activities that provide a kind of meaning to their days but lead nowhere socially. The path of least resistance is to “hir[e] companions like psychics and crystal healers rather than make friends.” Rich schizophrenics’ loneliness can be intense. They are beset by “affluenza”: failing to develop a sense of responsibility or “grit” is bad for anyone, but it’s particularly incapacitating for someone with serious mental illness. Family expectations can be overbearing. Gong mentions one client who was up for a job at a P. F. Chang’s restaurant until his parents nixed it, believing he could “‘do much better.’” We normally think of rich people as being freer than the poor, but Gong emphasizes how, for the seriously mentally ill, a formerly homeless person living unbothered—to a fault, perhaps—in a Housing First apartment has more personal freedom than his affluent counterparts, who are often subject to family paternalism. (To be clear, having a family in the picture is optimal. Seriously mentally ill adults with means tend to have many more family connections than their poorer counterparts; the family variable in Sons, Daughters, and Sidewalk Psychotics makes it hard to isolate which elements of inequality in mental-health care are purely economic.)
Middle-class families caring for a seriously mentally ill loved one are priced out of the highest-end boutique interventions. And Medicaid sometimes provides readier access to social-service-style benefits than does middle-class families’ commercial insurance. Some do, indeed, wind up invoking the “public option,” moving their relative off the family plan and onto Medicaid.
Why aren’t there better mental-health options for the middle class? Gong’s best guess is that the market is warped by wealthy families’ demand for quick-fix interventions. What’s really lacking are long-term care options: custodial programs that shelter and supervise chronically mentally ill adults at a reasonable cost and an adequate level of quality. The market currently doesn’t deliver this.
Gong’s fieldwork was extensive: he spent years tagging along with outreach teams, interviewing current and former street homeless as well as families with seriously mentally relatives at all income levels, volunteering at the Los Angeles County Department of Mental Health, and “spen[ding] nights in homeless encampments.” His argument about social control notwithstanding, Gong’s sympathies lie with Housing First and other public programs, as currently designed.
As to why public programs aim so low, Gong believes that much of the answer lies in “austerity,” but he puts too much stock in this concept. California’s mental-health system, well-resourced by American standards, does not seem like the best specimen for assessing austerity. That’s especially because, to borrow language from progressives, “austerity is a choice.” Community-based programs such as Housing First rose to prominence based on claims that they are inexpensive. But it takes money to help the hardest cases effectively. That reality has been systematically downplayed, over the years, by advocates who tout cost-savings analyses with about as much intellectual integrity as a Crazy Eddie TV commercial. In America, the normal tendency of government spending is to rise. We can talk about whether some areas of health and social policy should be prioritized over others, but that would require more nuance than the concept of austerity affords.
Read properly, though, Sons, Daughters, and Sidewalk Psychotics points the way to a more honest debate about community mental health. Housing isn’t health care. Third-party insurance-payment mechanisms are a strange fit for care for the seriously mentally ill, whose needs are more complex than short-term medical interventions can provide. Claims about how capitalism causes injustice in mental health should be discounted in view of rich people’s weakness for quacks and cure-alls. Though much of Gong’s analysis emphasizes differences between modes of care for the poor and rich, readers may find something tragically unifying about the challenge of untreated serious mental illness.
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