每天一篇经济学人 | Mental health 精神健康（2022年第106期
In America’s big cities, a walk down the street or a wait for the subway can be an exercise in avoidance. Scores of commuters in Los Angeles, New York and elsewhere don metaphorical blinders every day in order to ignore those sleeping fitfully on the train or battling psychosis on the street. Such indifference is morally fraught, but it is also a reflection of how common homelessness and public displays of mental illness have become.
在美国的大城市里，沿街散步或等地铁都是一种躲避行为。在洛杉矶、纽约和其他地方，许多通勤者每天都戴着“隐形”眼罩，以忽略那些在火车上断断续续地睡觉或在街上与精神病抗争的人。这种冷漠在道德上令人担忧，但这也反映出无家可归和公开展示精神疾病的现象已经变得多么普遍。
Most Americans who experience homelessness do so briefly. They stay with family or crash on a friend’s couch until they can afford rent. (The lack of affordable housing is the biggest driver of homelessness.) The Department of Housing and Urban Development’s latest count of homeless people, tallied on a single night in January, found that 22% of them are “chronically homeless”, and that there were 16% more perennially homeless adults in 2022 than in 2020. Many live in tents beneath highways or in public parks. They are more likely to be suffering from drug addiction and mental illness, both of which can be made worse by living on the streets. The number of people sleeping outside has increased by roughly 3% since 2020, cancelling out the modest decline of people in shelters. As the ranks of unsheltered people have grown, an old question re-emerges: how should government help people who may not be able to help themselves?
大多数经历过无家可归的美国人都短暂的这么做过。在付得起房租之前，他们要么住在家人家里，要么睡在朋友家的沙发上。(经济适用房的缺乏是导致无家可归的最大原因。) 美国住房和城市发展部HUD在1月份的一个晚上对无家可归者的人数进行了最新统计，统计发现其中22%的人是“长期无家可归者”，2022年长期无家可归的成年人比2020年多16%。许多人住在高速公路下或公园里的帐篷里。他们更有可能患有毒瘾和精神疾病，流浪街头会使让两种疾病变得更加严重。自2020年以来，露宿街头的人数增加了约3%，这与避难所人数的小幅下降相抵消。随着得不到庇护的人越来越多，一个老问题再次出现: 政府应该如何帮助那些可能无法自助的人?
The places most troubled by this, New York City and California, are trying to find an answer. Both have enacted policies aimed at people who are homeless and suffering from a psychotic disorder, such as schizophrenia. Yet they differ in important ways. Last month Eric Adams, the Democratic mayor of New York City, instructed police and first responders to hospitalise people with severe mental illness who are incapable of looking after themselves. Mr Adams’s plan is a reinterpretation of existing rules. Law-enforcement and outreach workers can already remove people from public places if they present a danger to themselves or others. But now, the mayor stressed, people can be hospitalised if they seem merely unable to care for themselves. “It is not acceptable for us to see someone who clearly needs help and walk past them,” Mr Adams proclaimed.
纽约和加利福尼亚州是受此困扰最严重的地方，它们正试图找到答案。这两个地区都制定了针对无家可归者和精神分裂症等精神障碍患者的政策。然而，这些政策在一些重要方面存在差异。上个月，纽约市长、民主党人埃里克•亚当斯指示警察和急救人员，将无法自理的严重精神疾病患者送进医院。亚当斯先生的计划是对现有规则的重新解释。如果有人对自己或他人构成危险，执法人员和外联工作人员已经可以将他们从公共场所赶走。但现在，市长强调，如果人们似乎仅仅是无法照顾自己，他们就可以住院治疗。亚当斯先生宣称:“ 我们不能接受看到明显需要帮助的人却从他们身边走过。”
The mayor’s plan follows a policy change on the opposite coast. At the urging of Gavin Newsom, California’s Democratic governor, the state legislature passed the Community Assistance, Recovery, and Empowerment (CARE) Act in September , creating a new civil-court system aimed at directing the mentally ill and homeless to treatment and housing. Patients can be referred to CARE court by police, outreach workers, doctors or family members, among others.
市长的计划是根据对岸的政策变化而制定的。在加州州长、民主党人加文·纽森的敦促下，加州立法机构于9月通过了《社区援助、康复和赋权法案》(CARE)，建立了一个新的民事法庭系统，旨在指导精神疾病患者和无家可归者接受治疗并提供住房。病人可以由警察、外联工作人员、医生或家庭成员等人转诊到CARE法庭。
Acceptance into the system means court-ordered treatment for up to two years, after which patients can “graduate” or, potentially, be subjected to more restrictive care, such as a conservatorship. California has been quick to try to distance CARE court from New York’s apparently more punitive response. “It’s a little bit like apples and giraffes,” says Jason Elliott, Mr Newsom’s deputy chief of staff. “We’re both trying to solve the same problem, but with very different tools at our disposal, and also really different realities.”
被该系统接受意味着法院下令进行长达两年的治疗，之后患者可以“毕业”，或者可能受到更严格的护理，比如监护。加州迅速行动以试图将CARE法庭与纽约那显然更具惩罚性的回应拉开距离。“这有点像苹果和长颈鹿之间的关系（意指“毫不相干/不同”），”纽森的副幕僚长杰森•埃利奥特表示。“我们都在试图解决同样的问题，但我们使用的工具非常不同，现实情况也非常不同。”
The biggest difference between the two policies is their size. Because New York City recognises a right to shelter, the vast majority of the roughly 68,000 homeless people there have a roof over their heads. Experts reckon that Mr Adams’s order may at first affect only those few hundred people in the most dire straits. The California Policy Lab at the University of California estimates that 10% of unsheltered people in Los Angeles who took part in street outreach programmes had been diagnosed with a psychotic disorder of the kind that CAREcourt is supposed to help manage. Because more than 100,000 Californians are sleeping rough, the state thinks that up to 12,000 people may initially be eligible for treatment.
这两项政策最大的不同在于它们的规模。由于纽约市认可庇护权，该市约6.8万名无家可归者中的绝大多数人都有栖身之所。专家们认为亚当斯先生的命令一开始可能只会影响到那些处境最艰难的几百人。加州大学的加州政策实验室估计，在洛杉矶参加街头外展项目的无家可归者中，有10%被诊断患有carec法庭应帮助管理的那种精神疾病。由于超过10万加州人露宿街头，该州认为最初可能有多达1.2万人有资格接受治疗。
A swinging pendulum
The schemes may be different, but the outrage they inspire is similar. Any discussion of compulsory treatment for the mentally ill is tangled up in a decades-long fight over the balance between protecting people’s civil liberties and bodily autonomy, and ensuring their safety and that of others. Officials and critics alike are squeamish about any reform that evokes the horrors of state-run asylums in the 20th century, which were often unsanitary, overcrowded and understaffed, and sometimes just cruel. When government-run hospitals were shut down, community-based care was supposed to take their place. Instead, patients were often discharged to underfunded boarding houses and shelters. “We have not only abandoned people with severe mental illness to the jails, but also to the streets,” says Elizabeth Bromley, a psychiatrist at UCLA.
这些方案可能有所不同，但它们引发的愤怒却是相似的。任何关于对精神疾病的强制的讨论，都与长达数十年的斗争纠缠在一起，其中斗争的焦点主要是在保护人们的公民自由和身体自主权，以及确保他们和其他人的安全之间取得平衡。官员和评论家们都对任何会让人想起20世纪官方收容所的不愉快经历的改革都感到不安，这些收容所通常不卫生，人满为患，人手不足，有时甚至很残忍。当政府经营的医院被关闭时，社区医疗应该取而代之。相反，病人经常被送到资金不足的寄宿公寓和收容所。加州大学洛杉矶分校的精神病学家伊丽莎白·布罗姆利说:“我们不仅把患有严重精神疾病的人扔进监狱，还把他们扔到街上。”
Many liberals blame Ronald Reagan for the government’s abandonment of mentally ill Americans. As governor of California in 1967, Reagan signed a landmark bill for patients’ rights, but then cut funding for mental-health care. As president in 1981, he rescinded federal funds for state mental-health services. But Alex Barnard, a sociologist at New York University, argues that heaping blame on Reagan is too simple. “Many administrations in California have had opportunities to reverse Reagan,” he says. Perpetuating the myth of Reagan’s total culpability, he adds, is “a way of distracting ourselves from the real challenge of building a system today that meets people’s needs, rather than just wishing we had it 50 years ago.”
许多自由主义者指责罗纳德·里根抛弃了患有精神疾病的美国人。1967年，作为加州州长，里根签署了一项具有里程碑意义的病人权利法案，但随后削减了精神健康保健的资金。1981年担任总统时，他取消了为州精神健康服务提供的联邦资金。但纽约大学社会学家亚历克斯·巴纳德认为，把责任推到里根身上是件简单的事。他表示，“加州的许多政府都有机会推翻里根”。他补充说，持久化里根完全有罪的错误观念是“在分散我们注意力，让我们忽视今天建立一个满足人们需求的体系的真正挑战，而不是只是希望我们50年前就拥有它。”
Civil-rights advocates in both states worry that the new policies herald a swing of the pendulum back towards confinement. It is unclear how often mentally ill people are detained for examination or treatment, but recent research suggests that the average yearly detention rate in 22 states increased by 13% between 2012 and 2016. Many critics argue that involuntary treatment is not only brutal, but ineffective. But the evidence is mixed and conducting research is tricky, says Mr Barnard. “You can’t randomly assign people to voluntary and involuntary treatment if you think that somebody is at risk of killing themselves,” he explains. Mr Adams’s plan and Mr Newsom’s CARE court both aim to exhaust options for voluntary treatment before mandating medication or hospital.
这两个州的民权倡导者担心，新政策预示着钟摆将再次转向监禁。目前尚不清楚精神病患者被拘留检查或治疗的频率，但最近的研究表明，2012年至2016年，22个州的平均年拘留率增加了13%。许多批评人士认为，非自愿治疗不仅残忍，而且无效。但巴纳德表示，证据是复杂的，进行研究也很棘手。他解释说:“如果你认为某人有自杀的风险，你就不能随机地将他们分配到自愿和非自愿的治疗中。”亚当斯先生的计划和纽森先生的CARE法庭都旨在在强制药物治疗或医院治疗之前，用尽自愿治疗的选择。
Logistical questions abound, too. Luke Bergmann, the director of behavioural health services in San Diego County, worries about how severely ill, often isolated patients are supposed to travel to their court appointments, and whether there will be enough beds in long-term care facilities to house them. Watchdogs on both coasts wonder what kind of clinical training police will receive, and whether racial bias will lead to worse outcomes for black and Hispanic homeless people. Brian Stettin, Mr Adams’s senior adviser for mental health, admits that confrontations with police can be traumatic, and stresses that cops will work alongside medical workers.
后勤方面的问题也很多。圣地亚哥县行为健康服务中心主任卢克·伯格曼担心，病情严重、经常被隔离的患者应该如何前往法院，以及长期护理机构是否有足够的床位容纳他们。两岸的监管机构都想知道警察将接受什么样的临床培训，以及种族偏见是否会导致黑人和西班牙裔无家可归者的结果更糟。亚当斯先生的心理健康高级顾问布莱恩·斯泰廷承认，与警察的对抗可能会造成创伤，并强调警察将与医务人员一起工作。
That Mr Newsom and Mr Adams are rethinking involuntary treatment reflects the failures of America’s mental-health system, but also their recognition that homelessness represents a political problem for their administrations—and their careers. As unsheltered homelessness has grown, Americans have become accustomed to public displays of profound suffering. Californians routinely say that homelessness is one of the most important issues facing the state; New Yorkers worry most about crime.
纽森和亚当斯重新思考非自愿治疗反映了美国精神健康系统的失败，但也反映了他们认识到无家可归对他们的政府和他们的职业生涯来说是一个政治问题。随着无家可归者的增多，美国人已经习惯了在公众面前展示他们深切的痛苦。加州人经常说，无家可归是该州面临的最重要的问题之一; 纽约人最担心的是犯罪问题。
Allowing the mentally ill to languish in the streets contributes to a feeling that public safety and quality of life in America’s biggest cities are deteriorating. Mr Newsom and Mr Adams are two of the Democratic Party’s most charismatic and ambitious politicians. Should either seek higher office one day, they will be asked what they did to solve the hardest problems in their respective domains. Now they will at least have an answer.
让精神疾病患者在大街上受苦，会让人觉得美国大城市的公共安全和生活质量正在恶化。纽森和亚当斯是民主党最有魅力、最有雄心的两位政治家。如果有一天他们寻求更高的职位，他们将被问及他们是如何解决各自领域中最棘手的问题的。现在他们至少有了一个答案。
