Conservatives have lately wanted public policy to focus on the interests of families. This welcome development has brought important reforms to K–12 public education, among other things, but it has overlooked mental health, where families’ needs are profound. In that policy area, decades ago, families took on a central role as government scaled back asylum-based care for adults with serious mental illnesses such as schizophrenia and bipolar disorder. “Community integration” is now the goal of the American mental-health-care establishment. Providers want mentally ill adults to live, as much as possible, the same way other people do — to have a normal life. To reach that goal, someone, or some entity, has to help integrate them into communities, and that task more often than not falls to families. A seriously mentally ill adult without much family support will have a tougher time living anything like a normal life than one who does have such help.

Families bear great burdens under the community-integration regime. That severely troubled man you sometimes pass during your morning commute: Imagine being responsible for him. Imagine having to argue with him day in and day out over taking his meds, about why his attendance at that reputable day program has been dwindling, and whether the CIA is spying on him. The mentally ill have trouble holding down a job and performing basic tasks such as grocery shopping. They have difficulty interpreting social cues, so they may not grasp, for instance, that a person is kidding. Their personal hygiene can leave much to be desired. They can be convinced that celebrities or long-dead historical figures are their personal confidants and that total strangers are passionately in love with them. Though the failings of American mental-health care are often attributed to “stigma” about mental illness, a deficit of shame can be just as great a problem. Were mentally ill people more responsive to what other people thought of them, their lives and those of their family members might run more smoothly.

Conversation, for psychotic people, is often not a two-way street. They mutter and mumble, speak in “word salads,” and are confused about normal social boundaries. A mentally ill adult may fail to grasp his neighbors’ objection to his breaking into their house to try on their clothes and take a bath. Integration into society requires developing tolerance for stress and learning not to spout out obscenities or offensive slurs. In her 1990 book Out of Bedlam, social worker Ann Braden Johnson remarks that “to get along in the world, schizophrenics, for example, need to learn that it is not all right to talk openly to one’s ‘voices’ (auditory hallucinations) on a bus or in a store, nor is it okay to menace strangers with dire warnings and threats, however important it may seem at the time to communicate the information.”

When made responsible for the care and treatment of a psychotic adult relative, families face tragic zero-sum choices about the distribution of emotional and material resources. Bonds between non–mentally ill children and their harried parents weaken or fail to develop in the first place. The roles and responsibilities of well siblings become especially complex when parents grow too old to care for their mentally ill adult child. (Smaller average family size may well have increased social isolation among mentally ill Americans.) Having two parents in the picture is, of course, best. But because the prognosis of serious mental illness is so uncertain, discussions over the course of treatment often set parents at odds. Relations grow estranged between nuclear families and cousins, aunts, and uncles. Strains within families in turn strain communities. Living next door to a schizophrenic man living with his single mother who’s working three jobs may be just as unnerving as living next door to a homeless shelter or a group home for single adults with a serious mental illness.

In the 19th century, state governments set up asylum systems in part for the benefit of families. Low-income and working-class parents at that time were not expected to provide 24/7 supervision of a 25-year-old schizophrenic son with disturbing tendencies. That was the government’s responsibility. If for some reason a family was reluctant to commit a troubled relative, the community would pressure them. This pressure was sometimes motivated by intolerance, and was sometimes of a more benign character, but in any event came as a predictable reaction to the absence of any community-based resources that could help families stabilize their loved ones at home. Progressive reformers established institution-based mental-health services at the same time that they were expanding K–12 public education and other public services. Pro-community, pro-family, and progressive: That’s how the old asylum regime was originally viewed.

We shut down that system through a process known as “deinstitutionalization.” It was catastrophic in many ways and certainly went too far. But anyone who appreciates the power of local, civil-society-based responses to social problems must at least sympathize with the idea. Families can employ a higher degree of sensitivity and dedication than massive government programs staffed by unionized bureaucrats, which is what most asylums were. What families lack in credentialed psychiatric expertise they make up for in their knowledge of their loved one’s capacities and quirks.

One of the hottest topics in mental-health policy today is how to restructure 911-response protocols to reduce fatal police shootings of the mentally ill. Cops responding to an “emotionally disturbed person” call often face split-second decisions over whether someone’s behavior is dangerous or merely eccentric. Families will usually grasp that distinction better than even the most experienced social worker or cop trained in the latest de-escalation techniques.

In addition, government caseworkers often complain about having too many clients. But when a mentally ill adult has a caring family member, he has, in effect, an unusually committed caseworker with a client load of one. There is a high turnover rate on the staffs of public programs, and many nurses and caseworkers are hired on a per diem basis. In this environment, caregivers don’t form bonds with patients or have an emotional investment in their well-being. A family-centered care regimen, in contrast, can help establish a “continuity of caregivers.”

Even when there is a family providing care, the government has a necessary role. It can take away people’s freedom and redistribute resources, two powers that civil society does not have and that are indispensable for a functional mental-health-care system. And no family would want to go without subsidized health insurance or income support for an adult schizophrenic child.

Housing is a more complicated problem. Many mentally ill adults living on the streets of San Francisco or New York would like their own private apartment. But for some of them, there is clearly such a thing as too much privacy (particularly when drugs are in the picture). Their families may not put a private apartment for their loved one at the top of their list of needs. Some disability advocates say that rental assistance for the mentally disabled is a crucial and benign social support akin to building ramps for people in wheelchairs. Don’t listen to them. Listen to the families.

Some of the most harmful and anti-family mental-health policy comes as a result of decisions made to advance other policy agendas unrelated to mental illness. The mentally ill, disproportionately to their share of the population, have always been avid participants in the vice economy: smoking, alcohol, street drugs. They are certain to be profoundly affected by the ongoing legalization of drug use and other antisocial behaviors. The seriously mentally ill use marijuana, for instance, at a rate three times that of adults who don’t have a mental illness, and there’s evidence that it exacerbates psychosis.

A November 2022 article in the New York City news outlet the City profiled one mother’s struggles in trying to keep her mentally ill adult son stable. One of the many things not going right in this man’s life was his addiction to online gambling. His mother faced a choice between, on one hand, assenting to his demands for money she couldn’t easily spare, which would only feed his addiction, and, on the other, getting into conflict with him. If cities legalize prostitution, and bipolar women sign up to be licensed “sex workers” at rates disproportionate to their share of the population, will that be celebrated as a victory for disability rights?

Normalizing antisocial behavior is often termed “harm reduction.” That concept is usually sold as a straightforward cost–benefit analysis: the costs of enforcing laws against drug use and other illegal activities, weighed against the benefits of preventing their harms. But such calculations focus too narrowly on the impact of “harm reduction” on the individual. Fentanyl addiction and untreated schizophrenia inflict profound harm on entire families. That’s perhaps the most distinct way in which behavioral-health disorders (psychiatric and substance-use) differ from health problems such as heart disease and cancer. From the perspective of families, illegal drug use is far from a “victimless” crime, and untreated schizophrenia traumatizes and can endanger everyone in the family.

Any family-oriented mental-health agenda should begin by reforming the Health Insurance Portability and Accountability Act (1996). That law imposes privacy restrictions on health information that keep family caregivers in the dark about the course of treatment for their adult child. The mental-health system uses HIPAA to stonewall parents when they’re seeking information as vital as whether their child has been hospitalized. In his recent book Malady of the Mind, Dr. Jeffrey Lieberman recommends changing privacy laws to authorize disclosing treatment information to caregivers when withholding it would cause a patient to deteriorate or if the patient lacks the mental capacity to follow the treatment plan on his own.

One of the more nightmarish rituals of family members is to monitor “inmate finder” websites run by local corrections agencies. Jail is a terrible place for a person with schizophrenia, but for many families, knowing that their loved one is locked up is preferable to not knowing where he is or whether he’s alive. One key practice for handling schizophrenia is to maintain health records for medication regimens, since settling on an effective antipsychotic course can require much trial and error, and a change in medication can send a person back into psychosis. Keeping records is not easy for someone with a disorganized mind, but his parents or siblings can help. HIPAA, however, stymies the free flow of information between doctors and family caregivers that would enable more effective treatment.

Mental illness is a chronic condition that often involves recurring crises too severe to be handled at home. Treatment therefore sometimes requires confinement in a hospital. The mentally ill commit a disproportionate share of intra-family violence in America. That problem attracts far less attention than fatal police shootings do, but it’s larger. A 2016 study by the Treatment Advocacy Center estimated that more than 1,000 family homicides annually are committed by people with serious mental illness. The Washington Post maintains a database of fatal police shootings going back to 2015. Since then, no year has witnessed more than 260 fatal police shootings of mentally ill people.

To reduce intra-family violence caused by mental illness, we need to replenish our stock of inpatient psychiatric beds. Beds in public psychiatric hospitals are down more than 90 percent since the mid 1950s, and they’ve recently been declining in general hospitals as well. One major problem is that hospitalizing the seriously mentally ill is one of the least remunerative lines of business for private health systems, so they’ve been converting psych beds to other uses. Another problem is that Medicaid won’t pay for most care for adults in large, specialized hospitals.

We also need to change norms to encourage greater use of powers that are already available, such as assisted outpatient treatment (AOT) and conservatorship. Those programs use the legal system to implement formal but community-based supervision of the seriously mentally ill. In AOT (known as “Kendra’s Law” in New York and “Laura’s Law” in California), a judge orders a seriously mentally ill adult to comply with a treatment plan custom-tailored for him. AOT’s success at reducing incarceration, homelessness, and other notorious adverse outcomes of untreated mental illness has been documented by multiple studies.

Conservatorship is a process through which courts transfer authority over the affairs of an individual deemed mentally incapable of managing them to a third party, sometimes a family member. It gained a bad rap for its use on Britney Spears, who was placed in a conservatorship in 2008 after having been twice committed to a psychiatric ward. Whatever may have gone wrong in that high-profile case, conservatorship can be a vital institution for families of those who have a serious mental illness. The purpose of both AOT and conservatorship is prevention. Moderate forms of coercion help families prevent crises that would otherwise necessitate confinement in a hospital or jail.

Whether society is made up of families or autonomous individuals is one of the classic questions of political philosophy. It’s also a question that can have immediate life-or-death consequences for the mentally ill. The stakes are understood well by civil-liberties advocates. As one recently said to the Los Angeles Times: “We understand that family are important; they are the support systems often. . . . However, ultimately, when it comes to involuntary treatment, it’s the individual whose civil liberties will be jeopardized.” But policies to benefit the mentally ill have to be made on behalf of the mentally ill. Families are more-effective agents than professional advocates, because of their intimate involvement and because they must bear the consequences of flawed ideas. Civil-liberties advocates’ unnuanced “maximum freedom for all” approach harms some of the most vulnerable among us, that small percentage of mentally ill Americans who are imprisoned by psychosis and for whom, therefore, “freedom” is a virtually meaningless ideal. Civil libertarians have many crimes to atone for in the history of mental-health policy, but perhaps none so serious as tearing families apart. What’s good for families is good for the mentally ill.