M.D.s Call for Community Resources Amid Plans to Force Homeless Into Care

The directive issued on November 29 by New York City Mayor Eric Adams instructs police, EMTs, and other city workers to involuntarily transport homeless, mentally ill individuals to the hospital for evaluation who appear unable to meet their basic needs, even without a recent threat of violence or dangerous act. This includes people with a serious untreated physical injury or an “unawareness or delusional misapprehension of” their surroundings or their own physical condition, the directive states.

Adams’ directive follows a string of violent attacks and homicides in the city’s subway system. It comes on the heels of an interpretive guidance issued by the OMH last February that clarified that individuals who display an inability to meet their basic living needs meet the standard for “dangerousness to self” and involuntary removal from the streets.

“It is not acceptable for us to see someone who clearly needs help and walk past,” Adams said when announcing the directive. “If severe mental illness is causing someone to be unsheltered and a danger to themselves, we have a moral obligation to help.”

To support the directive, Adams announced the creation of the following to help individuals experiencing a mental health crisis:

The mayor is also pushing state legislators to pass a mental health legislative agenda that includes expanding the state’s standard for providing involuntary treatment. It calls for authorizing a wider range of clinicians, including psychologists and social workers, to determine an individual’s need for involuntary care.

According to the Coalition for the Homeless, Adams’ plan “ignores that many people cannot access psychiatric care even on a voluntary basis,” the group wrote. In fact, of the nearly 94,000 individuals with serious mental illness in New York City who are eligible for enhanced mental health services under the state’s Medicaid managed care program, only 2.3% (less than 2,200) received it. Adams’ directive aimed at homeless people with mental illness “gets it wrong” by relying on ineffective surveillance, policing, and involuntary transport and treatment, the group concluded.

The city’s directive has been largely misunderstood, said Paul S. Appelbaum, M.D., the Dollard Professor of Psychiatry, Medicine, and Law and director of the Center for Law, Ethics, and Psychiatry at Columbia University. He added that the state has an interest in protecting people who are unable to meet their basic needs. “There’s an intrinsic humanitarian imperative not to stand by idly while these people waste away.”

Following the closure of many state mental hospitals in the 1960s, commitment standards around the country were narrowed to apply solely to individuals who were deemed dangerous to self, dangerous to others, or unable to meet their basic needs, known in some states as “grave disability,” explained Appelbaum. “The mayor’s initiative is simply an effort to extend police and EMT actions to the full scope of the statutory criteria. It doesn’t represent a change in the law, so much as a change in the practice in the field.”

Steven K. Hoge, M.D., director of the Columbia-Cornell Forensic Psychiatry Fellowship Program, agreed and said he supports the mayor’s directive. “There’s been some concern in New York state that the civil commitment criteria have been interpreted too narrowly. ... Ultimately, the mayor’s directive may be useful in resetting expectations on how we look at the homeless mentally ill population in New York City and whether we consider them appropriate candidates for humane interventions.”

“The reality of clinical judgments in emergency rooms is that they’re contingent on the availability of resources,” Hoge continued. “If there are no beds or very few beds, you’ve got to be very strict about whom you involuntarily admit to the hospital.”

Edward Herman, M.D., J.D., president of the New York State Psychiatric Association, expressed doubt that the new directive will have a significant impact on addressing the large number of people with mental illness who cycle between hospitals and the streets. He said any solution to assist people with mental illness must include re-opening the more than 1,000 inpatient psychiatric beds that were shuttered in the state at the height of the COVID-19 pandemic. Currently, 850 of those beds are still devoted to general medical use.

Many individuals with mental illness who are homeless in New York remain so because they don’t feel safe in the housing options presented to them, Herman continued. “For example, shelters are a very threatening environment for this population because they’re vulnerable and preyed upon,” he said. “The lack of housing essentially drives them to the streets and the subways, and not having housing is a major barrier to accessing treatment.”

E. Fuller Torrey, M.D., founder of the Treatment Advocacy Center and associate director for Research of the Stanley Medical Research Institute, called Adams’ approach “a brave effort to solve a difficult and increasingly serious problem.” While Torrey said he agrees that the best outcomes result from a collaborative approach, he has found that most seriously mentally ill patients with anosognosia won’t agree to treatment because by definition they do not believe there is anything wrong with them. (Anosognosia is a symptom of severe mental illness that impairs a person’s ability to understand and perceive his or her illness.) His analysis of 25 research studies on anosognosia found that it is a biological problem with the brain, similar to that seen in Alzheimer’s disease and some cases of stroke.

All the psychiatrists interviewed agreed that the success of involuntary care initiatives will hinge on the establishment of reliable aftercare systems, including more community mental health services, supportive housing, “wraparound” services that include case management, and court-ordered outpatient care.

Koh also called on cities and states to adopt evidence-based treatment models, such as intensive multidisciplinary teams such as Assertive Community Treatment and “housing first” models, which allow for immediate housing without precondition. Other promising approaches include street outreach, supportive employment, crisis diversion, peer support, and homelessness prevention efforts, she said.

Appelbaum added, “Without this investment, we’ll simply see a revolving door where people are brought in and within a relatively short period of time will be back out on the streets and subways. If that’s the case, police will just stop bringing people in because they will perceive that there’s no benefit in doing so.”

Nationwide psychiatric bed capacity has dropped steadily for the past 50 years, and one recent study found that one-third of states have fewer psychiatric beds than the estimated 35 beds per 100,000 people needed, according to Christopher Hudson, Ph.D., and colleagues in the International Journal of Environmental Research and Public Health in 2021. That may be a conservative estimate of the shortfall: A widely cited study by the Treatment Advocacy Center found that 40 to 60 psychiatric beds are needed per 100,000 population. (APA has created a model to determine the number of beds and other services that a community needs to provide adequate mental health services: “The Psychiatric Bed Crisis in the United States: Understanding the Problem and Moving Toward Solutions”.)

Appelbaum pointed out that a model exists for providing care to individuals with homelessness and serious mental illness known as Assisted Outpatient Treatment (AOT). It is court ordered and includes medication as a condition of remaining in the community. In the last 30 years, all but three states have adopted some form of AOT. Research shows it holds promise as a way of helping seriously mentally ill people avoid hospitalization, incarceration, and homelessness.

However, these laws are rarely utilized because of lack of funding for the community resources they require, Appelbaum said. Another barrier may be the laws themselves. According to data compiled by the Treatment Advocacy Center in 2020, 16 states have ambiguous or incomplete AOT laws that hinder their application. That is slowly changing: A number of states have passed laws in the last several years to widen and clarify the standards to compel individuals into AOT, including Alabama, Hawaii, Pennsylvania, Texas, Utah, and Washington.

California’s Community Assistance, Recovery, and Empowerment Act, known as the CARE Court law, takes the AOT concept to the next level. (“Calif. Law Creates New Civil Court for People With SMI Facing Incarceration or Homelessness”). CARE plans will span one to two years and include housing, county mental health and substance use services, stabilization medications, wellness and recovery supports, social services, legal representation, and a volunteer supporter to help individuals make “self-directed care decisions.”

Whereas in the past only clinicians could petition the court, CARE Court also allows family members, roommates, first responders, and others to refer individuals in crisis to be evaluated for a court-ordered, community-based care plan. Only adults with severe untreated schizophrenia spectrum or psychotic disorders will be eligible, an estimated 7,000 to 12,000 people.

“The CARE Court law breaks significant new ground, in that it assigns the court a new role in compelling public mental health systems to provide services to specific individuals,” said Roderick Shaner, M.D., co-chair of government affairs at the Southern California Psychiatric Society. “The law’s effectiveness will be limited, however, by its reliance on an outdated, incomplete definition of grave disability due to mental illness.

“We now know that serious mental illness impairs the ability of individuals to accept potentially lifesaving interventions for both physical and mental conditions,” Shaner continued. “We will continue to push for legislative changes to modify the definition of grave disability due to mental illness by adding the inability to provide for one’s own needs for critical medical care.”

Seven counties are now scrambling to implement CARE Court by October, including San Francisco, Orange, and San Diego, with the rest of the state required to implement no later than December 2024. The framework is supported by California’s $15.3 billion investment to address homelessness, including $1.5 billion for behavioral bridge housing, according to Newsom’s office. The state is also spending more than $11.6 billion a year for mental health programs. An additional $63 million will go to the counties to establish CARE Courts.

California’s CARE plans are court ordered but stop short of forcing individuals to take medication. However, participants whose condition is deteriorating may eventually be placed in conservatorship or institutionalized. The National Alliance on Mental Illness (NAMI) California praised CARE Court as a “lifeline” to thousands “looking for help to live a more fulfilling life.”

Meanwhile, ACLU California along with a slew of disability and homeless advocates vehemently condemn the law, saying it unnecessarily involves the courts and legal system, criminalizes homelessness, disproportionately impacts people of color, and fails to provide the necessary housing and community mental health care.

“CARE Court is a fast-track to re-institutionalize Californians living with mental health disabilities,” Kim Pederson, senior attorney at Disability Rights California, said in a statement.

Facing criticism from business owners over the number of individuals camping on the streets, Portland Mayor Ted Wheeler said that he wants to make it easier to force people living on the streets into hospitals, even if they do not pose a threat. His plan includes increasing the number of police officers in regions of the city with homeless camps and conducting more “sweeps.” Wheeler is also pushing for a citywide ban on public camping and wants to force homeless residents into large city-run encampments, which have yet to be funded or built.

Stephanie Maya-Lopez, M.D., co-chair of the Oregon Psychiatric Physicians Association Legislative Committee, said the mayor’s call to involuntarily hospitalize people who are homeless and mentally ill in Portland would be “impossible on a practical scale.” She cited the mayor’s lack of authority over the matter, lack of available psychiatric inpatient beds, and decades of case law by the Oregon appellate courts requiring imminent threat of harm to self or others as a minimum standard for commitment.

“Moreover, turning to the hospitalization and involuntary detention of a human being as the default solution to a social problem is not appropriate. There are people who do need involuntary commitment, and we need expansion of services of all levels of care, both in the community and in psychiatric inpatient hospital beds,” she said. “However, it needs to be psychiatrically appropriate to put someone in a hospital against his or her will.”

Massachusetts General’s Koh emphasized that involuntary commitment should be used as a last resort—when other outreach and services have failed. Still, she keeps in mind an anecdote shared by one of her close colleagues who wrestled with whether to hospitalize a woman with schizophrenia who lived on the streets for 10 years. Eventually, the colleague involuntarily hospitalized the woman, and she began taking medication, secured housing, and did very well. When her colleague later saw the patient, she demanded, “How dare you leave me on the streets for so long?”

“We’re trying our best to help these individuals and preserve their autonomy and dignity, but is it really autonomy if their thought process is clouded by a thought disorder? What about people’s right to be treated for a treatable mental illness? I think this needs to be weighed very carefully,” Koh concluded. ■