Psychiatric Hospitalization Does Not Solve Homelessness

In November 2022, New York City Mayor Eric Adams unveiled his plan to address the city’s ongoing problem of unhoused citizens with severe mental illness. The new directive empowers first responders, including law enforcement, to detain an individual involuntarily for formal psychiatric evaluation if deemed mentally ill and unable to meet their basic needs. Early data indicates that at least 42 New Yorkers were brought involuntarily to city hospitals by mobile crisis teams since the implementation of the new policy in early December, although some contend that the actual number, including those transferred by police, may be much higher.

Homelessness is a growing concern in major metropolitan areas throughout the United States. On her first day in office, Los Angeles Mayor Karen Bass issued an emergency declaration on homelessness, an issue that was central to her campaign. Strategies to reduce homelessness are desperately needed, but New York City’s new mayoral directive poses considerable consequences for the future provision of mental health care and fidelity of the doctor-patient relationship.

Emergency department visits for mental health complaints have risen steadily since the onset of the Covid-19 pandemic. In a cross-sectional analysis of approximately 190 million ED visits, higher rates were noted for suicide attempts, drug and opiate overdoses, intimate partner violence, and child abuse and neglect at the height of the pandemic in 2020. Increased demand for care has outpaced the supply of trained psychiatrists and other providers, resulting in protracted wait times for care (also known as “boarding”) for patients requiring psychiatric hospitalization. Exacerbating demand through detainment of individuals experiencing homelessness without expansion of other mental health services and workforce development risks further escalation of what is already an ongoing crisis of need.

Differences in training between police officers and mental health professionals may increase profiling under an involuntary detainment policy. Efforts to enhance officer education around mental health crisis response, including Police Crisis Intervention Training (CIT), are admirable and have demonstrated meaningful officer-level outcomes such as a decrease in stigma towards mental health patients in crisis and self-perceived decreases in the use of force. New York City officials have reportedly devised training programs for crisis management among first responders. In emergency departments, however, formal psychiatric assessment of the need for involuntary psychiatric hospitalization is more robust and requires not just a clinical interview, but also a review of past mental health records and contact with collateral sources that can corroborate a patient’s recent level of functioning and any potential decline or lack thereof. The depth of assessment is more extensive than what police training provides.

Involuntary psychiatric hospitalization is a restriction of rights not to be taken lightly. As an emergency psychiatrist who has performed these assessments in large, urban academic medical centers for over 15 years, it is often necessary to balance the risk of future debility and suffering from an untreated psychiatric illness (the chance a patient may complete suicide) with the potential benefit of involuntary hospitalization. Sometimes the calculus is clear and leans heavily towards the benefit of admission. In other instances, the burden of one’s psychiatric illness – although in need of clinical care – does not meet the legal threshold to warrant taking away an individual’s right to autonomy. Under New York City’s plan, some patients thought to be in need of involuntary psychiatric admission may be discharged after a complete psychiatric assessment. This “revolving door” will prove taxing to both patients as well as law enforcement.

Invoking involuntary psychiatric hospitalization for individuals with homelessness also stands to weaken the doctor-patient relationship. The cornerstone of psychiatric assessment is bedside empathy and therapeutic alliance. I often share with patients that all I know of their experience is what they choose to share. This choice to disclose and show vulnerability in crisis rests heavily on trust and accord, and New York City’s plan weakens these essential attributes of good care. The implications are significant, unfounded involuntary psychiatric assessment discourages engagement with future care when most needed. A 2022 review in the Journal of Nervous and Mental Disease found that involuntary detainment is associated with decreased adherence to future care plans as well as a greater sense of patient humiliation and loss of dignity, especially when police intervention and physical restraint are employed. Patients respond much better to partnership rather than coercion.

Some may find merit in Mayor Adams’ approach to involuntary hospitalization. Proponents of the policy note that proactively transferring patients in need of psychiatric care to hospitals may decrease the criminalization of mentally ill persons by preventing further decompensation that may otherwise lead to illegal acts. But this viewpoint is short-sighted when considering the long-term influence of such coercion on one’s willingness to remain in care longitudinally. The chronicity of mental illnesses requires long-term partnership with care rather than forced deprivation of autonomy.

Psychiatry as a discipline is founded on the effort to understand and accept others. Empathy is a central tenet of such work, especially in crisis intervention settings like emergency departments. Any social policy – however well-intentioned – that infringes on this basic premise and deprives patients of choice without due consideration of the likely repercussions, is likely to be unsuccessful and detrimental to well-being.