This month I had the privilege to speak to members of the Rotary Club in a modest-sized city in California. One of their focus issues for 2016–17 is the problem of homelessness. I spoke about the failures of our mental health system, which has left so many people with serious mental illness untreated and living on the streets.
My brother-in-law is a real estate developer in the city. Before my talk, he took me on a tour of the homeless encampments in town—one of which is on property he owns. Every six months or so he receives a notice of violation from the city, informing him that the encampments are in violation of city codes and that he must remove the people from his property. He does so, which costs his firm thousands of dollars. Where do the homeless go? They rebuild their encampments in another part of town until they are removed from there, at which time they move back to my brother-in-law’s property. Clearly, the notice of violation is no solution to the underlying problem.
What is the underlying problem? There are numerous factors that may lead to homelessness (e.g. domestic violence, substance abuse, unemployment), but one of the most important is untreated mental illness. Estimates suggest that, nationwide, one-third of homeless persons have a serious mental illness (SMI). In some places, the proportion of mentally ill among the homeless is even greater: 70% in Roanoke, Virginia (2007) and 67% in Colorado Springs (2009). [Torrey 2014; TAC 2015] Most homeless people with serious mental illness are not receiving treatment; many do not even know they are ill.
In his book American Psychosis, E. Fuller Torrey gives the following account of one homeless man with a serious mental illness:
"In Kennebec, Maine, a severely mentally ill man dug a cavelike home for himself in a hillside beneath a downtown parking lot. He rejected all offers of help by police and mental health workers, and Maine law did not allow for involuntary treatment except under extreme circumstances. Finally, the overlying city parking lot began to sag because of his digging, and it was decided to arrest him because he was a threat to the parking lot. [p. 124]
There is something very wrong with a system that makes it easier to arrest a homeless person than to get him the treatment he needs. But the laws in Maine are typical of most states. Only 18 states allow involuntary hospitalization for mental illness on the basis of "need for treatment." [Stettin et. al. 2014] Most states prohibit involuntary inpatient treatment for those with SMI unless they pose "an imminent danger to themselves or others" (a.k.a. someone has been hurt), or they are "gravely disabled" (a.k.a. they have so neglected their basic needs that their life is in danger). Presumably, these laws protect the rights of persons with serious mental illness to make their own decisions about the treatment they receive. Those rights ought to be protected, except when a person is so acutely ill that they are incapable of making rational decisions about their need for care.
Mental illnesses are diseases of the brain. When the symptoms of mental illness are acute, they affect an individual’s decision-making capacity. Our failure to provide treatment for people in this situation is equivalent to neglect. Would we allow an elderly parent with Alzheimer’s disease to wander around the streets? Of course not. Then why do we allow persons with serious mental illness to live homelessly, rousted from one property to another, without receiving the treatment they need? It is not a matter of civil rights. There is no fundamental right to be mentally ill.
In fact, the United Nations Convention on the Rights of Persons with Disabilities specifies that "Persons with disabilities have the right to enjoy the highest attainable standard of health, without discrimination on the basis of disability." [Stettin 2014] Clearly, persons with untreated mental illness, who might respond to treatment with antipsychotic medications, are not enjoying "the highest attainable standard of health." Our failure to provide treatment to those in need is essentially discrimination against persons with mental illness.
Legal restrictions are not, however, the only barriers to providing necessary care for persons with acute mental illness. There are resource constraints as well. The U.S. mental health system in 2016 simply does not have the capacity to provide short-term psychiatric hospitalization for all those in need of care. Despite the fact that spending on mental health services increased dramatically between 1970 and 2000, the number of psychiatric beds per 1,000 population decreased by 70%. [Frank and Glied 2006] Today, there are shortages of beds in almost every state.
Why did the resources flowing to mental health services not increase the supply of inpatient beds for psychiatric care? Because the economic incentives that contributed to the deinstitutionalization of the mentally ill in the latter half of the 20th century continue to discourage hospital treatment for mental illness today. Medicaid (established in 1965) provides health insurance for persons with low income. Medicaid funds cannot, however, be used to pay for care provided in an "institution of mental disease" (the IMD Exclusion Rule). Supplemental Security Income (SSI, established in 1972) provides monthly stipends to help pay the living expenses of persons with low income. Patients in nursing homes, group homes for the mentally ill, or other living situations, can receive SSI, but patients in psychiatric hospitals cannot.
You do the math! As a state legislator, you can care for persons with SMI in a state psychiatric hospital, supported by state tax dollars. Or, you can opt for outpatient care, or care in another institution, and receive federal assistance through Medicaid and SSI. The states did the math. Between 1955 and 1976, nearly 400,000 patients were released from state mental hospitals. Today, the capacity for inpatient psychiatric care in public hospitals is so limited that, in some states, the only way to guarantee a bed is to arrive in the custody of the police.
I told the Rotary Club that we cannot address the problem of homelessness effectively without recognizing its correlation with serious mental illness. We must also address the economic and legal barriers that make it difficult, or impossible, to get people with acute symptoms of SMI the treatment they need. Clearly, providing notices of violation to helpless property owners is no solution to the problem. Telling ourselves that people who live on the streets "choose to be homeless" is an abdication of our responsibility to the less fortunate. Among the homeless population, those with serious mental illness can be identified, treated, and placed in living situations that provide the basic necessities of life. Let’s get on with the business of solving the problem instead of simply moving it around.
Frank, Richard G., and Sherry A. Glied. Better but Not Well: Mental Health Policy in the United States since 1950. Baltimore: Johns Hopkins University Press, 2006.
Stettin, Brian et. al. "Mental Health Commitment Laws: A Survey of the States." Treatment Advocacy Center, 2014.
Szmulker, George et. al. "Mental Health Law and the UN Convention on the Rights of Persons with Disabilities." International Journal of Law and Psychiatry 37 (2014) 245–252.
Torrey, E. Fuller. American Psychosis. Oxford: Oxford University Press, 2014.
Treatment Advocacy Center (TAC). "How Many Individuals With a Serious Mental Illness Are Homeless – Backgrounder." June 2016. http://www.treatmentadvocacycenter.org/problem/consequences-of-non-treat...