Is it Time to finally Intervene with the Homeless Severely Mentally Ill?
“Serious mental illness (SMI) is defined as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. The burden of mental illnesses is particularly concentrated among those who experience disability due to SMI”. “In 2020, there were an estimated 14.2 million adults aged 18 or older in the United States with SMI. This number represented 5.6% of all U.S. adults” (Ref.1). It appears that a small fraction, probably the most severely affected of these millions, approximately 125,000, become homeless nationwide, with an increase in mortality, rarely living past 50 y/o (Ref.2).
Why is it that many of the most severely mentally ill become homeless living in the streets and not under appropriate psychiatric care? The factors leading to this situation were well reviewed in a 1984 essay in the New York Times. It began in the 1960’s with an over reliance on new psychotropic drugs without recognizing their limitations, along with the impression by the public that the existing state mental hospitals were ineffective and “snake pits” with exorbitant costs. At the same time there was an over reliance on community health centers based on a Missouri pilot study of their efficacy that could not be reproduced when in general use. A 1963 federal law funding community centers around the country for four and ½ years assumed the states would pick up the tab thereafter, but that did not materialize. Civil libertarians fought for social justice for the homeless mentally ill as a class, not understanding that in some few cases institutionalization against their will was in the best interest of both the patient and society. Institutionalization, however, must be based on clinical criteria by qualified physicians and could in many cases be temporary and requiring far fewer beds than existed in the 1960’s. The net result of these several factors is summarized in the initial paragraph. “The policy that led to the release of most of the nation’s mentally ill patients from the hospital to the community is now widely regarded as a major failure. Sweeping critiques of the policy, notably the recent report of the American Psychiatric Association, have spread the blame everywhere, faulting politicians, civil libertarians and psychiatrists”. (Ref.3).
The situation has festered for decades with severely mentally ill persons being homeless, posing a danger to themselves and to others. Over time several well intentioned interest groups have posed solutions to alleviate this problem without success, probably in large part because they do NOT understand the inherent difficulties of being rationale when having severe untreated mental illness (Ref.4) In November 2022, the mayor of New York City, Eric Adams a former police officer, decided that because the situation had become so severe with violence on the streets and in the subways perpetrated by severely mentally ill individuals, a different approach was necessary. He announced a plan to train police how to respectfully bring patients for psychiatric evaluation in additional hospital beds supported by the state for much needed care. Special arrangements will probably be needed if long term therapy is necessary. He emphasized that this is not only a safety factor for the public but importantly in the patient’s best interest. As expected, some advocacy groups are voicing their strenuous objections (Ref.5,6). A plan such as this can only survive if based on individual needs and long-term benefit for patients. Society has a requirement for the safety of both the general population and the mentally ill.
- National Institute of Mental Health, Mental Illness, January 2022, available at: https://www.nimh.nih.gov/health/statistics/mental-illness (accessed November 28, 2022)
- Smiljanic Stasha, The State of Homelessness in the US – 2022, Policy Advice, September 29, 2022, available at: https://policyadvice.net/insurance/insights/homelessness-statistics/ (accessed November 29, 2022)
- Richard D. Lyons, How Release of Mental Patients Began, The New York Times, October 30, 1984, available at: https://www.nytimes.com/1984/10/30/science/how-release-of-mental-patients-began.html (accessed November 27, 2022)
- Stephen Eide, How to Think about Homelessness, National Affairs, Fall 2018, available at: https://nationalaffairs.com/publications/detail/how-to-think-about-homelessness?mkt_tok=NDc1LVBCUS05NzEAAAGIckVOH_nLlBhgk6KB7MRAlaW0glh (accessed December 2, 2022)
- Andy Newman, Emma C. Fitzsimmons, New York City Involuntarily Remove Mentally Ill People From Streets, New York Times, November 29, 2022, available at: https://www.nytimes.com/2022/11/29/nyregion/nyc-mentally-ill-involuntary-custody.html(accessed November 29, 2022)
- Bobby Caina Calvan, Mayor says NYC will treat mentally ill, even if they refuse, AP News, November 29, 2022, available at: https://apnews.com/article/health-new-york-city-mental-government-and-politics-21d32260d21bee4ac87a81a55234ba11(accessed November 30, 2022)
arf, Thanks for your comment, pretending that the homeless situation is something we just have to accept is not in the interest of the homeless or of the community. Ken
The toughest patients were the paranoid schizophrenics. They’re paranoid and won’t take meds if they were out patients. Were always off the deep end. Was a shame to see. When I got out of residency and started to “really” practice, I had some schizophrenics on very low dose psychotropes (like 5mg of Zyprexa a day) who were married, with jobs and doing well. Couldn’t tell they were different from anyone else. I asked them, “What if you don’t take the psychotrope?” Oh man they replied they would get terribly symptomatic. Shoot Zyprexa or Seroquel really isn’t considered a drug of abuse so I didn’t try to stop it with anyone in that position. Convinced me that mental illness was on a spectrum. Some have it “bad” and some “not so bad”.
Kurt, Thank you for responding, I believe you are correct a spectrum of disease. Each individual must be evaluated and appropriately treated. I believe psychiatrists need to be more involved with the homeless severely mentally ill. Ken
Portland Oregon.
A Portland City Council candidate rented 3,000 square feet of downtown Portland office space for his political campaign. A Portland real estate mogul had advertised the space for rent at a little less than $7,000 a month.
The office space was rented to this political candidate for $250 a month….that’s TWO HUNDRED FIFTY DOLLARS…..plus utilities, which is about $500 a month. So a massive discount, about 96% discount.
A discount like that, to a political campaign, should be considered an “in kind” contrbution and reported under campaign finance laws, and it was not reported by the politician.
So the politician gets fined about $77 grand.
Politician appealed.
Judge ruled there was no violation of campaign finance laws. Fine was set aside.
The real estate mogul can advertise property for any price he wants, seven thousand dollars a month or seven million. What counts is what the property is actually worth. What the property is actually worth, is what someone is willing to pay.
The judge ruled that current downtown Portland conditions…….homelessness, crime, drugs, needles, filth…..makes downtown Portland real estate essentially worthless.
The judge felt two-hundred-fifty a month plus utilities is reasonable for the times. The campaign is doing the property manager a favor in a way, just by being there, it’s security, watching out for squatters, meth labs, and a political campaign might have enough political pull to get the city off it’s ass to actually police the area. So two hundred fifty is about right.
So we now have, for the record, a judge saying that homelessness with the resulting crime, drugs, filth, huan excrement, needles……makes downtown Portland real estate worthless.
https://www.portland.gov/sites/default/files/2022/appeal-order.pdf
arf, Thanks, I think the judge is totally correct. To me dealing with the mentally ill about 1/4-1/3 of the homeless population is a necessary first step. Ken
This is what I miss about Portland. Remember this poster from the 1970’s?
https://m.media-amazon.com/images/I/71Plb5ezlgL._AC_SY879_.jpg
https://upload.wikimedia.org/wikipedia/en/7/78/Expose_Yourself_to_Art.jpeg
“Expose Yourself to Art”
The guy in the trench coat is Bud Clark. Born in 1931, he enlisted in the Marines, then went to Reed College in Portland, a fairly intense intellectual campus. He dropped out junior year, opened a tavern in the Goose Hollow neighborhood just southwest of downtown Portland. At the time, Goose Hollow was a fairly crappy neighborhood (not any more).
In ’78, he made the poster as a fund raiser for a Venereal Disease nonprofit. Sold for a buck apiece at the time, they sold a quarter million copies.
About six years later, the guy in the trench coat ran for Mayor of Portland. He won, and served two terms. Then he went back to running hs tavern.
He was a left-wing populist, he did work with the homeless problem at the time. Yet somehow the crime and the drugs and the filth could be kept under control.
Portland has been weird, left-wing, offbeat for generations. Yet somehow they kept it together. Somehow the city lost a certain je ne sais quoi and has descended into a hellhole.
These institutions were called “asylum” for a reason. They were protecting the mentally ill person from the world.
arf, Perhaps in the old days too many mentally ill were in asylums, but today the most severe need constant attention. Thanks for your thoughts. Ken
Pat, Thanks for your input. Would it be possible to think of dealing with the severely mentally ill on the streets as a first step in your suggestion of remote holding areas? Ken
Ken, For those willing to accept it, if the locals can figure out a way to make it work, I say Great! I’m not for forcing anyone to do or accept anything, and I certainly don’t have all the answers. You describe a very real, serious problem, only a portion of which even makes it to the ER.
I am skeptical that the severely ill can be dealt with on a voluntary basis, and therefore look at using actual law violations (not BS, phony police-state charges) as an opportunity to intervene. For those who refuse any help and are not actually violating the law, squatting, etc, then only voluntary outreach on the local level would seem appropriate. Would it help? Some, certainly not all.
Pat, I look upon it as a begging of dealing with the homeless problem. I do think if a severely mentally ill appears to be a danger to others and themselves they should be involuntarily hospitalized even if for a short period of time. Ken
1. The mayor of NYC is full of shit. This is all lip service without actual teeth, and is being used for political cover in exactly the same way that his utterly ineffective anti-crime rhetoric has been.
2. Federal dollars to failed community health centers demonstrate yet again, tiresomely, that the federal government cannot, should not have any interaction with the provision of routine or chronic care not involving the VA. None. And that includes all you Medicare and Medicaid types.
3. Civil libertarians (like myself) have gotten the order of things wrong. When vagrants are camping out on sidewalks and in subway terminals, they violate the civil liberties of the taxpayer. That should have always been the focus, and local municipalities should have – and could – establish more remote holding facilities for those arrested for squatting; in which food, temporary shelter, and medical evaluation could be provided. Society should protect its productive members FIRST, akin to putting on one’s own oxygen mask before helping the neighbor with his. I am not at all arguing against due process, but recognize that no practical or moral purpose is served by allowing bums, drug addicts, and otherwise mentally ill to damage communities in the name of pursuing some vague equivalency between those who own businesses and those who run their customers off by defecating and shooting drugs in front of their doorways.
This is a tough problem which will always be with us, and there are no easy or one-size-fits-all solutions. But the long-term needs are not more important than those of the law-abiding community, and should not continue to drive this search for solutions.
Wow. Boldly stated, and the best way I’ve ever heard that truth stated. Impressive. You have given words to my vague thoughts. Homelessness is a problem, but often forgotten is the truth that choices matter. most homeless people have absolutely broken the hearts of their family members that begged them to get help. Drugs are a choice. Mental illness is not, but taking meds for it is.
Ken, Thank you for your positive comment, it has been about 50 years that this issue has been ignored. It is certainly time to try something other than the vague comment, lets build more homes. There is more to being homeless than not having a home. Ken