Putting a Band-Aid on NYC's Unhoused

By Jane Gagliardi, M.D.

“Being homeless, no matter how long it lasts, is a life-altering traumatic event that creates major stress in any person’s life, regardless of age.” — Homelessness Programs and Resources | SAMHSA

During an early morning run with a colleague in Los Angeles several months ago, we ran past three separate people sleeping on the sidewalk. I imagine there were more people in a similar circumstance that I didn’t notice.

More recently, while visiting New York City with a family member, we ventured onto a street near Central Park where a lone man stood in the middle of the sidewalk, screaming. I could not tell if he was screaming at us or whether he was perceiving something I could not, but his distress was unmistakable. Shaken, we hastily crossed to the other side of the street and away from what felt like a dangerous situation. Although I recognized the suffering of a fellow human being that day in NYC, my family member and I were still concerned about our own safety.

Were these individuals unhoused? And if so, why? From a position of relative safety and privilege (such as knowing where we will be sleeping tonight), one might imagine unhoused individuals as mentally ill and threatening public safety. Hence, they should be removed from the streets. One might also be tempted to attribute their unfortunate lot in life to bad personal choices (as addiction is popularly characterized) and attributes. However, there are other—less voluntary—factors at play in people’s lives that lead to housing insecurity and financial instability.

Issues of housing and homelessness are a matter of longstanding personal interest because, for decades, my father worked in the business of nonprofit housing to secure decent, affordable housing for individuals in low to moderate-income brackets. He believes, as do I, that housing, like healthcare, is most appropriately viewed as a basic human right.

Thinking of my recent experiences, if I had never seen the screaming man or any other unhoused person, I might wrongly imagine the problems of inadequate housing and mental illness had been successfully addressed in NYC. Not witnessing these problems, it would be possible to assume that they didn’t exist—or the predicament facing so many people might not even cross one’s mind.

Quick Fix in NYC

Yet NYC Mayor Eric Adams has identified a quick-fix remedy that may appeal to the sensibilities of privileged New Yorkers and visitors to the city. In December, he created a policy that would allow law enforcement officers to involuntarily transport houseless individuals who appeared to be mentally ill to hospital emergency rooms for assessment based on an evident inability to meet their basic needs. Putting a humanistic spin on the policy, Mayor Adams added, “it is not acceptable for us to see someone who clearly needs help and walk past.”

But does bringing houseless individuals for potential psychiatric treatment actually constitute help? Does the policy do enough to address the problems that lead individuals to housing and financial insecurity?

Dr. Ruth Shim, a psychiatrist, leader, and advocate for justice in society and healthcare has published extensively on the complex and multifaceted relationship between mental illness and social injustice. Shim identifies income inequality, education inequality, poverty, inadequate access to food, and disparities in opportunity, situating these factors within longstanding historical and sociocultural contexts of prejudice, exclusion, and racism. These structural factors in American society—the same ones that predispose some people to poverty and housing insecurity—can also undermine physical and mental health. Once the vicious cycle of lack of housing and worsening health starts, it can be challenging and even nearly impossible for individuals to regain a position of stability and relative wellness.

In other words, psychiatric illness might be a symptom of inadequate housing instead of a root cause of it, and being without housing may reflect systemic failures more than individual deficits.

My own experience over the years working in inpatient and emergency medical and psychiatric settings has been that a significant proportion of individuals who present in psychiatric crises also experience inadequate housing. This experience is also borne out by studies. For example, rates of mental illnesses, including psychosis, PTSD, and addiction, range from 3-54 percent among individuals without housing as compared to 1-16 percent among housed individuals. Yet are they unhoused due to an untreated psychiatric illness, or are they psychiatrically ill because they are unhoused? If we are successful in determining the direction of the association, we are more likely to be able to advocate for and adopt policies that target the root causes and result in improvement.

It is important to note that although individuals without housing are significantly more likely to exhibit mental illness than individuals who have adequate housing, it is not necessarily the case that every houseless person is mentally ill or that every housed person is without mental illness.

And what happens when a law enforcement officer tries to commit an unhoused individual for psychiatric treatment who does not have a mental illness? Agitation, in and of itself, is not a mental illness. No one can expect police officers to do in-depth diagnostic examinations, yet the first step in determining the appropriateness for involuntary commitment is a diagnostic assessment by a qualified clinical professional.

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What Are the Laws?

Most state laws stipulate the presence of mental illness as a prerequisite to involuntary commitment proceedings. New York State’s Mental Hygiene Law further specifies that involuntary commitment is appropriate when a “person has a mental illness for which care and treatment in a mental hospital is essential to his/her welfare; person’s judgment is too impaired for him/her to understand the need for such care and treatment; as a result of his/her mental illness, the person poses a substantial threat of harm to self or others.”

Unfortunately, today’s mental health system is clogged with demand that has for decades outpaced the supply of adequate treatment. For patients without private insurance or means to pay out of pocket, inpatient, intensive outpatient, and close follow-up can be challenging or impossible to find.

Even if a sufficient number of inpatient psychiatric beds and adequate treatment to address all of the mental illnesses existed, involuntary commitment proceedings and assisted treatment based on immediate dangerousness are not applicable for the majority of unhoused individuals—whether or not they also suffer from mental illness.

Further, the premise of inability to meet one’s own basic human needs—the explicitly invoked way the mayor’s policy qualifies unhoused individuals as “dangerous to self”—will not be magically solved by a brief stay on an inpatient psychiatric service.

However considered, involuntarily detaining unhoused individuals is unlikely to be helpful. Regardless of the circumstances surrounding psychiatric admission, medications and psychotherapy are not the remedy to the financial and housing crises individuals face. In fact, according to the NY-based Coalition for the Homeless, lack of affordable housing is the number-one cause of inadequate housing for the thousands of New Yorkers who lack a stable place to sleep at night. Increased linkage to shelters, also mentioned in the mayor’s policy announcement, are a temporary strategy, not a solution to the problem.

In the psychiatry emergency department, I witness many patients whose traumatic life experiences and psychiatric illnesses can be tied to psychosocial factors and societal shortcomings. Temporary hospitalization is unlikely to satisfactorily address either medical and psychiatric illnesses or the barriers many individuals encounter in obtaining adequate support to meet other basic human needs.

Instead, there are many caring individuals and organizations in NYC with programs designed to help vulnerable people with addiction and/or mental illness achieve stability in health and housing, though requirements for insurance, funding, abstinence from substances, and complicated application procedures may be deterrents for participation by unhoused individuals just trying to get by.

So while permitting police to pursue involuntary commitment may clear the streets during the winter holiday season and may prevent me and my family member from feeling uncomfortable when we walk near Central Park, it is unlikely to help the individuals who are suffering at least as much from systemic injustices and societal ills as from psychological and psychiatric ailments.