A Roadmap for Helping People Who Are Homeless and Mentally Ill

Coauthored by Samuel Jackson, MD, Kenneth Minkoff, MD, and Stephanie LeMelle, MD

Hundreds of people walked obliviously by Julian in his makeshift shelter daily. Wrapped in tarps and plastic bags on the corner of a busy Brooklyn intersection, the only obvious signs that Julian lived there were the smell–stale alcohol and urine–and his shoes.

Now in his 60s and having spent the better part of 18 months on this corner, Julian appeared gaunt, with a shrunken jaw and a toothless smile. He appeared at times to be talking to the voices in his head.

In addition to a diagnosis of schizophrenia and alcohol addiction, Julian suffered from severe osteoarthritis in his left knee and walked with a well-worn cane. Although Julian had “chosen” the street, he was not at all “safe,” and as winter came on, he was in danger of dying in the cold.

In December, New York City Mayor Eric Adams issued a controversial directive to have police and others involuntarily remove mentally ill people from the city's streets and take them to hospitals. As he put it, “It is not acceptable for us to see someone who clearly needs help and walk past them.” His announcement is just the most recent flashpoint in an ongoing debate about how best to provide crisis services for people with mental illness who are experiencing homelessness.

Further complicating matters, the unhoused population is a large, heterogenous group of individuals who have unique challenges when engaging with existing forms of crisis intervention. Homelessness is multifactorial, often a result of poverty, and is frequently compounded by struggles with mental illness, substance use disorders, and a sense of community rejection.

Therefore, while necessary in the most acute crises, involuntary removals and hospitalizations should not be the default approach as that often results in people being more traumatized after discharge from a psychiatric hospital than before admission. And while needed medications can be started in the hospital, this does not end homelessness, nor are medications sufficient to address all of the needs of the homeless mentally ill.

Adams’s announcement has also drawn attention to the need to improve behavioral health crisis services for everyone, not just the unhoused mentally ill. The challenge communities face is building a behavioral crisis system accessible to all—but also one capable of meeting the unique needs of people experiencing homelessness. Ideally, a behavioral health crisis system, like the existing Emergency Medical System (EMS), should be able to treat all populations, at any stage of illness, anytime, anywhere, including those experiencing homelessness.

Toward that end, the Committee on Psychiatry and the Community of the Group for the Advancement of Psychiatry (GAP) has produced The Roadmap to the Ideal Crisis System: Essential Elements, Measurable Standards, and Best Practices. It provides detailed guidance for communities aspiring to transformative change and who are seeking to achieve the same standards of access and excellence as the existing medical crisis system.

The Roadmap envisions a community’s behavioral health crisis system that must be more than a single program or collection of services but rather a coordinated system with a governance and accountability structure that ensures individuals’ needs, including housing, are met effectively and efficiently.

Among the many hundreds who passed by him, at least one person noticed Julian, recognized he was “in crisis,” and called the 988 hotline for help. However, the crisis line did not respond with police and involuntary admission as a first step. Instead, they dispatched a street outreach team, which included a trained mental health professional, which engaged Julian several times over the following few weeks.

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The team spoke to Julian directly as a person and learned he was fearful of shelters and hospitals based on prior traumatic experiences in them. He was also adamant about not taking medications and had no interest in abstaining from alcohol. Although he needed a place indoors before winter, he was ambivalent about returning to a shelter, not knowing he had other options.

The street outreach team eventually connected Julian to a local safe haven, a “low-barrier” transitional housing space specifically tailored for chronically unsheltered individuals who may be resistant to accepting traditional shelters or traditional housing and mental health services.

With a focus on a goal of permanent supportive housing placement, Julian was allowed to come and go as he pleased, intoxicated or not, while receiving three hot meals a day, showers, and connections to care, including on-site housing specialists, case management, primary care, and psychiatry.

After several weekly meetings with the safe haven team and significant continued outreach, Julian became open to starting a medication to treat his schizophrenia. He shared his talent for singing but still continued to drink. Often forgetting to take his medication and weary of any team monitoring, he was nonetheless helped to make slow and steady progress. For the first time in a year-and-a-half, he was off the streets, engaging in treatment and becoming part of a community.

A year later, Julian was transferred to permanent supportive housing with similar on-site services provided by the same organization. Although the move had been planned, Julian was reticent to engage with the new, unfamiliar staff and went weeks without his medication, explaining, “I don’t want to start this all over again.”

Concerned about losing his progress and motivated to coordinate his transition of care, the safe haven team came to the new housing site to meet with Julian and his new team. With everyone together, the trust seemed to transfer. Julian felt more comfortable and decided to continue meeting with his new team. Julian’s final transition was making his new house a home.

Although Julian was helped without needing involuntary intervention, many people like him may have moments of crisis in which they are in immediate danger through self-neglect or risk of self-harm or violence. In such cases, involuntary intervention may be necessary for their and others’ safety. However, even then, the initial intervention should be designed to minimize the trauma experienced by the person in crisis and focused on ultimately developing the same kind of long-term trusting outreach that Julian received.

For some individuals, ongoing court supervision through Assisted Outpatient Treatment may be needed to promote engagement with support services, but engagement in voluntary, hopeful, supported housing is always the goal. A surprising percentage of individuals experiencing homelessness with mental illness and substance use disorders will benefit from intensive voluntary outreach and engagement alone.

Crisis intervention for unhoused people who have mental illness and/or substance use challenges should be unbiased, welcoming, and hopeful. It must also take into consideration the multiple traumas these individuals have endured. As with anyone in crisis, the focus must be on meeting the individual’s immediate needs and facilitating their continuing care.

Rather than starting by locking people up, communities should focus on what already works and scale it up comprehensively and systematically to meet community needs. For example, unhoused people with mental illness need relationship building, which ideally should be available before they are in crisis, throughout a crisis, and then continued as a crisis is resolved. Studies have shown that there are good models for voluntary crisis services. There are also effective models for providing supportive housing for people with mental health and substance use challenges.

Adams is right in that it’s not OK to have so many unhoused people, many with serious mental illness, who are not getting the help they need. However, this is not a problem unique to New York City and it is one for which evidence-based solutions exist.

Homelessness should not be treated as a crime. And even when involuntary care is temporarily needed, civil liberties and due process must be maintained while always keeping an eye on the ultimate goal of providing housing with dignity.