The US media is saturated with coverage of perceived threats to public safety by people experiencing homelessness (PEH) with purported “mental illness.” In a prescient 2017 article in the Journal of the American Medical Association (JAMA), then-Los Angeles health commissioner, Mitchell Katz, noted a sense of public “frustration with some of the behaviors of some homeless people,” ranging from “sidewalks being blocked by shopping carts, aggressive panhandling, and urination and defecation in public.”1 Such sentiments have intensified in recent years, as the number of PEH (Table 1) has surged, with frustration increasingly turning into fear. With regards to media coverage, a series of articles suggested that nearly half of commercial sidewalks in San Francisco were “covered in feces,” leading to widespread public outrage.2 Meanwhile, a content analysis of 6,400 tweets regarding PEH collected over three months showed widespread generalizations that PEH posed a high risk of violence and that homelessness was caused by untreated mental illness.3
Table 1.
Key Information About People Experiencing Homelessness (PEH)
People experiencing homelessness (PEH) are defined by the U.S. Department of Housing and Urban Development as individuals who lack or are at imminent risk of losing fixed, regular, or adequate nighttime residence.71 |
The number of PEH in the U.S. reached a record high in 2022 of 582,620.72 |
Unmet medical needs are common in PEH: |
Multiple states have begun passing legislation attempting to criminalize homelessness.
|
Much attention has focused on PEH in major cities along the West Coast, with California having the largest population of PEH for over a decade. Yet, Midwestern states have also seen a large increase in PEH, with Missouri having the greatest increase in unaccompanied and unhoused young people and minors in the US from 2019 to 2020.76 |
People of color are overrepresented among PEH. In an analysis of federal data, the overall prevalence of homelessness for Black individuals in the US was 3-fold greater than the rates of White peers,77 with the disparity as high as 4-fold in St. Louis78 and 10-fold in San Francisco.79 |
The framing of these narratives have been identified as further entrenching the dehumanization of PEH, contributing to oversimplified understandings of PEH and mental illness, and motivating policy interventions that are not evidence-based.4 Physicians’ lack of specific training in working with PEH can create additional barriers to accessing care,5 especially since PEH may perceive negative attitudes in their physicians,6 exacerbating feelings of alienation.7 Stigma is pervasive,8 and that experience is often compounded by PEH’s past negative experiences with medical care and ongoing structural barriers to engagement (e.g., transportation, payment).9 Against this backdrop, this review seeks to harness our expertise in forensic psychiatry, addiction science, health policy research, social work, and adult psychiatry to highlight potential misinformation and provide an evidence-based update for clinical generalists. We will also discuss evidence-based solutions for PEH, describing why long-term custodial psychiatric care and involuntary psychiatric hospitalization is unlikely to solve the ongoing crisis.
Mental Illness and Addiction Can Be One of Many Precipitants of Homelessness and Should Not Be Seen as the Underlying Cause
Mental illness is commonly assumed to be the cause of homelessness. However, homelessness is a complex health equity problem, as it is embedded in a web of structural determinants of health and has potential solutions that are often misrepresented to the public. Extensive research has shown that the strongest drivers of homelessness are related to poverty and housing affordability.10 People of color experience among the highest rates of housing instability (Table 1), attributable to unequal access to mortgages and race-based exclusionary tactics in real estate (redlining), among myriad other factors.11
While a person’s current state while homeless may be conflated as the cause of homelessness, homelessness itself can lead to trauma, victimization, problematic substance use, and serious mental illness, exacerbated by the dearth of community-based resources11 and, more recently, the COVID-19 pandemic.12 Moreover, cognitive disorders such as dementia and traumatic brain injury (TBI) are overlooked consequences of violence towards PEH. A recent systematic review showed that 53% of PEH had a TBI of any severity, noting that past TBI was associated with increased risk of victimization and intimate partner violence. Especially since it can contribute to worse psychiatric outcomes, TBI can be challenging “to manage in the best of circumstances and may complicate efforts at sobriety or housing stabilization.”11 To date, evidence-based strategies to diagnose and treat cognitive disorders in PEH are lacking.11,13
The interplay between homelessness and addiction is particularly complex. Longitudinal analyses show that relationships among addiction, mental illness, and homelessness are unlikely to be causal.14,15 For instance, in people with problematic substance use, adverse childhood experiences and trauma were stronger predictors of homelessness than addiction.16,17 Data collection on substance use statistics in PEH, already lacking, is further complicated by the fact that “substance use” does not equate “addiction,” especially as PEH may have consumed fentanyl and other potency-enhancing drugs unknowingly. Importantly, while the proliferation of fentanyl, methamphetamine, and other adulterant use in PEH have garnered much media coverage, alcohol use disorder is the most common substance use disorder in PEH18 (prevalence of nearly 40%11). While studies have shown important racial and socioeconomic disparities in alcohol use disorder screening and treatment in general adult populations in the US,19 PEH are not included in national surveys of substance use disorders, constituting a major research gap.
Homelessness and Mental Illness Are Not Driving Surges in Violent Crime
Homelessness and mental illness are often a public safety concern. However, PEH are more likely to be victims of crime than perpetrators,20 and rates of violent crime among PEH are lower compared to other types of crime (e.g., drug-related charges).21 A 2020 US Department of Justice study showed that approximately half of PEH surveyed reported being victims of violence, compared to 2% of the general population.22 When violence does occur in PEH, studies have suggested they often serve as a function of self-protection.23 PEH are at particularly high risk of being victims of both domestic violence, particularly women and LGBTQIA+ people,24 and are also at elevated suicide risk.25–27
Furthermore, although media depictions of violence in people with mental illnesses like schizophrenia are common,28 studies have not found significant relationships between most serious mental illnesses and future violent behavior.29 A major analysis led by Paul Appelbaum (The MacArthur Violence Risk Assessment study) involved longitudinal follow-up data on people who were discharged from inpatient psychiatric facilities. Appelbaum and colleagues showed that the prevalence of violence among people with serious mental illness—and no co-occurring addiction—was virtually indistinguishable from control subjects selected from the same neighborhoods. The authors suggested that when neighborhoods are unsafe and high in socioeconomic distress, violence risk was comparable in people with and without serious mental illness.30,31 Another notable study analyzed data from the social network of 169 people with serious mental illness for over 30 months, finding that among >3,000 social network members, only 1.5% were ever the target of violence, with the majority of them being family members and peers, not members of the general public.32
Problematic substance use has been hypothesized to confer a greater risk of perceived “violence” than other psychiatric conditions.33,34 While recognizing that PEH who use drugs may exhibit “challenging behaviors” that may be “perceived as but not necessarily result in violence,” researchers have suggested that 1) most violent acts are not committed by people with mental illness; and 2) addictive disorders may explain some of the increased risk of violence associated with psychiatric disorders.35 While there is a robust body of literature on the relationship between alcohol use disorder and aggression,36 studies have found that permanent supportive housing with access to mental health professionals—for PEH with alcohol use disorder have contributed to longitudinal decreases in use.37 Studies investigating the role of supportive housing for PEH who struggle with addiction have also observed decreased reoffending rates and criminal justice involvement with supportive housing placement.38 Importantly, access to supportive housing is associated with decreased risk of violence towards PEH, evidenced by programs that integrated suicide prevention, trauma-informed care,39 and case management with supportive housing.40
Permanent Supportive Housing is Cost-Effective and Associated with Better Outcomes for PEH
In addition to improving health outcomes for PEH, permanent supportive housing has been found to be cost-effective. For instance, a 2019 study randomized nearly 1,200 PEH in four large Canadian cities to either permanent supportive housing with intensive case management compared to treatment as usual, finding an incremental cost-effectiveness ratio of $56 per additional day of stable housing.41 The authors noted that the cost of the intervention, approximately $40 per participant daily, was within the range of costs for currently funded forms of shelter and supportive housing, and that costs for permanent supportive housing were offset by reductions in costs of shelters and emergency admissions.41 A separate economic valuation study noted that the benefit-to-cost ratio for permanent supportive housing studies in the US was 1.8 to 1, with a median averted cost of $14,193 per year from the judicial system or health care expenditures. (For reference, a recent estimate showed that it may cost local governments more than $30,000 per person experiencing homelessness annually in legal system, cleanup, and medical fees in Springfield, Missouri, via treatment as usual.42)
Unfortunately, efforts to provide permanent supportive housing and comprehensive interventions to prevent homelessness in the first place have been meager. Furthermore, the elevated rates of victimization and trauma in PEH would suggest a need for trauma-informed care, case-management, wrap-around services, and comprehensive psychiatric treatment. Yet instead of investment in these programs, supportive housing-first programs with case management, counseling, job training, and health care services have struggled to procure sustainable funding for renovations and expanded capacity, relying on small COVID-19 emergency funds.43
Putting People Away Without Essential Care and Basic Needs
We are seeing a push for locking people away (and out of sight) without increasing access to essential health care and basic needs. However, coercion is not a substitute for permanent supportive housing.
In public media, narratives on homelessness, mental health, and violence often suggest that involuntary psychiatric commitment and the use of law enforcement to implement involuntary holds are solutions for homelessness. Consequently, there is driving a public interest in the use of law enforcement and involuntary psychiatric care to address homelessness despite a lack of evidence for these measures. Specifically, involuntary psychiatric hospitalization is usually short-term whereas addressing either substance use or homelessness would require a long-term intervention. Yet, leaders in California and Oregon have discussed using involuntary holds to “combat homelessness.”44 New York City, in particular, has been in the spotlight for directing police and emergency personnel to hospitalize people deemed too mentally ill for themselves, even if they posed no threat to others,45 sometimes described as the “forced removal of mentally ill” people.46 Despite this push to use the threat of arrest and citation to compel people to seek treatment,31 studies show that law enforcement presence at substance use treatment sites may discourage people who use drugs from accessing health services.32 Overall, involuntary treatment for substance use is not supported by most psychiatrists.47
Importantly, the debate surrounding the merits of involuntary psychiatric treatment for PEH who are mentally ill—and the framing of untreated mental illness as a public safety problem—is not a new one. It can be helpful to consider the historical legacy of deinstitutionalization largely starting in the 1960s, which can be defined as the depopulation of psychiatric hospitals. Deinstitutionalization was motivated by a value for community integration and concern over the dehumanizing conditions within institutions, as well as by fiscal considerations. However, instead of reorienting psychiatry towards a community-based healthcare model, government support for comprehensive outpatient services, including for many PEH with serious mental illness, did not materialize.48 Meanwhile, the push for using law enforcement to involuntarily hospitalize PEH with a reported history of mental illness and psychiatric hospitalization who had not been convicted or charged in a crime has been gaining steam. In 1999, following the murder of Kendra Webdale by Andrew Goldstein, New York State passed the first assisted outpatient treatment (AOT) law (“Kendra’s Law”) in the US. As noted in a 2010 special section on AOT in Psychiatric Services, it was noted that “a judge may order a person with mental illness to adhere to recommended outpatient treatment” and that “nonadherence with a treatment plan may lead to a request that law officers transport the consumer to a treatment facility for encouragement to comply with treatment or evaluation for inpatient commitment.”49 In many cities, the encoding of AOT has authorized law enforcement officers to bring people with a reported history of mental illness to emergency rooms for treatment. While media narratives have suggested that Mr. Goldstein was not in “compliance” with his treatment, Mr. Goldstein had, in actuality, twice attempted voluntarily to participate in a Bellevue pilot program for psychiatric treatment but was turned away due to limited space.50
Even as AOT has expanded across the majority of US states,51 the results of AOT have been mixed at best. A highly controversial 2001 study by Swartz and colleagues sought to randomize involuntarily-hospitalized people to either be released from civil commitment or undergo outpatient commitment, with the authors contending that outpatient commitment lasting more than six months was associated with decreased hospitalization, arrests, acts of violence, and incidents of victimization.52 While the study was well-received by proponents of AOT, it was widely criticized for ethical issues, lack of blinding, as well as attrition, selection, and reporting bias.53 To this day, there remains concern that the effective ingredients in AOT are not necessarily compulsion, but rather the influx of money, resources, and staff support54 that often come along when AOT state laws are implemented. For instance, AOT in New York was accompanied by an infusion of new service dollars and featured “more comprehensive implementation, infrastructure and oversight of the AOT process than any other comparable program in the United States.”54 Further, AOT programs effectively allow people to “jump the line” ahead of others waiting for services voluntarily, potentially having the unintended consequence of further limiting voluntary treatment; this is amplified by the limited caseloads that case managers will have when serving AOT clients, as mandated in AOT statutes and regulations in many states so as to ensure that each AOT client receives comprehensive care.55 Meanwhile, a severe dearth of supportive housing and treatment capacity have limited the utilization and effectiveness of AOT throughout the US.56
In addition, acute psychiatric treatment via AOT does not equate long-term community-based care, as many people who are sent to the emergency room for acute stabilization are discharged with inadequate follow-up. Moreover, inpatient psychiatric hospitalization as a place for even brief psychiatric stabilization has been debated for lacking a robust evidence-base of its own; studies have noted that inpatient psychiatric admissions can be traumatizing for many patients,57,58 while also introducing disruption in economic, employment, interpersonal, and therapeutic domains.59 A recent study noted that young adults reported negative effects of involuntary psychiatric admission on trust, help-seeing, and engagement with clinicians, evidenced by the selective non-disclosure of suicidal ideation.60 Another analysis showed a widespread lack of electronic health information exchange at discharge from inpatient psychiatric care, hindering outpatient care coordination. 61 In addition, as noted in a recent review of the risks and benefits of psychiatric admissions, inpatient hospitalization may exacerbate employment instability and come with hospital bills that pose high financial burden to patients with unstable insurance coverage.59 Finally, the number of inpatient psychiatric beds owned by systems, for-profit companies, and behavioral health hospital chains have increased substantially in the last decade, per a recent analysis of the National Bureau of Economic Research’s Health Systems and Provider Database.62 Particularly amid the current enthusiasm surrounding the use of involuntary psychiatric hospitalization to combat homelessness, it is imperative for payers and policymakers to institute safeguards against profiteering, while monitoring trends in quality of inpatient care moving forward.
Learning “From the Misses” Does Not Breed Compassion
As complex as is the relationship between homelessness and mental illness, the provision of non-psychiatric medical care for PEH is not routinely included in clinical training. A systematic review and meta-ethnography on substance use treatment for PEH showed that compassionate support from medical staff was the most consistently mentioned component of effective treatment services.24 Yet, an analysis of emergency medicine residents illustrated a lack of didactic hours and formal curricula dedicated to learning about PEH, trainees reported feelings of frustration and futility amid a sentiment that they were primarily learning how to treat PEH “from the misses,” defined as cases where PEH had bad outcomes.63
While some studies have shown that medical trainees have adopted increasingly negative attitudes towards PEH over the course of medical training,64 there are nonetheless some signs of progress, as traditional academic medicine increasingly embraces health care for PEH in its formal curricula, both through clinical training and didactics illuminating health systems’ structural violence.65 Academic programs like Boston Health Care for the Homeless and Yale Street Psychiatry have been successful in integrating educational experiences surrounding PEH into clinical training.66,67
Yet, there is mounting concern about negative public opinion68 and compassion69 wearing thin amid perceptions of US cities being “taken over” by encampments.70 Meanwhile, resources that PEH may benefit from are often unavailable (i.e., trauma-informed care, permanent supportive housing, diagnosis and management of cognitive impairment). Since we cannot write a prescription for housing, it may be tempting for health care providers, when working with PEH, to “call for a psychiatry consult” to consider involuntary institutionalization, which may feel akin to the most immediate tool available to physicians seeking to help PEH.
Ultimately, we must not conflate the tools available to us in the hospital (i.e., involuntary psychiatric hospitalization for persons at imminent risk of harm to self or others) with structural solutions that address the underlying drivers of homelessness. As we have seen throughout history, carceral logic has bred carceral solutions. Decreasing the visibility of PEH does not make the problem go away.
Acknowledgment
Patricia Cavazos-Rehg PhD and Laura Bierut MD of the NIDA K12 Program of Washington University for obtaining funding to support effort for personnel (Dr. Xu, Dr. Szlyk).
Footnotes
Kevin Y. Xu, MD, MPH, (pictured), and Hannah S. Szlyk, LCSW, PhD, are in the Health and Behavior Research Center, Division of Addiction Science, Prevention, and Treatment, Washington University, and in the Department of Psychiatry, Washington University School of Medicine, both in St. Louis, Missouri. Jessica A. Gold, MD, MS, is in the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri. Stephanie A. Rolin, MD, MPH, is in the Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York. Morgan C. Shields, PhD, is at Brown School, Washington University, St. Louis, Missouri.
Funding/Support: Effort for the authors was supported by the National Institutes of Health (NIH K12 DA041449, Xu, Szlyk; K23MH126312, Rolin; L30MH120711, Rolin).
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