Thursday, April 13, 2023

Involuntarily Hospitalizing Homeless People With Serious Mental Illness May Backfire, Experts Caution

Two articles published yesterday in JAMA Psychiatry investigate the recent policy by New York City Mayor Eric Adams that expands efforts to hospitalize individuals with serious mental illness experiencing homelessness.

In November, Adams issued a directive to first responders, including police officers, paramedics, and outreach workers, instructing them to involuntarily transport individuals with mental illness who are experiencing homelessness to hospitals if they present a serious risk of harm to themselves or others. The directive also lowers the threshold of what is considered harm, instructing authorities to remove an individual from the streets or subway if he or she appears unable to “meet basic living needs, even when no recent dangerous acts have been observed.” Further, Adams outlined an 11-point legislative agenda that includes his top priorities to address at the state level and would add many of the initiatives included in his directive to the state code.

“One might say, here we go again,” wrote Michael Hogan, Ph.D., of Case Western Reserve University School of Medicine in his JAMA Psychiatry viewpoint. Hogan pointed out that past policies have similarly attempted to address the problem of people with mental illness experiencing homelessness, but the cycle continues.

Further, Adams’ policy pushes against current trends, Hogan wrote. The policy increases police intervention while significant work is being done in other areas to decriminalize people with mental illness, such as the implementation of the 988 National Suicide Prevention Lifeline. Additionally, he noted, there are benefits and drawbacks to increased hospitalization. While inpatient treatment will likely reduce symptoms for people with acute illness, involuntary hospitalization initiated by police can be traumatic and intrusive.

“A more substantial limitation of the proposal is the fact that access to ‘aftercare,’ principally stable housing and flexible treatment and support, is not ensured in the mayor’s plan,” Hogan wrote. “Without these, any value achieved through hospitalization is temporary, providing only time-limited clinical benefit.” A more effective approach is to provide access to housing—particularly permanent supported housing (which Hogan called “the gold standard for addressing homelessness”)—as well as continued, clinically competent, and engaging treatment.

In another JAMA Psychiatry viewpoint, Nick Kerman, Ph.D., of the Centre for Addiction and Mental Health in Toronto and colleagues wrote that Adams’ policy is an example of those policies that, in the absence of government investment, “lead people with mental illness experiencing homelessness to be moved ‘out of sight, out of mind.’”

“We believe that New York City’s policy approach is a violation of human rights, harms the personhood of people with mental illness experiencing homelessness, and that this policy will have deleterious effects on this population, mental health services, and evidence-based interventions for homelessness,” the authors continued.

Involuntary hospitalization in the absence of imminent risk threatens to further erode this population’s “self-determination in seeking health care and service engagement” and “heightens the power imbalance between people experiencing homelessness and those providing them with services,” they wrote. They point to several other negative impacts of the policy, including the following:

  • It perpetuates structural stigma in assuming people with mental illness experiencing homelessness cannot care for themselves and need to be hospitalized for theirs and others’ safety.
  • It overlooks why people with mental illness are living on the streets and not in shelters and does not address their concerns about safety in emergency shelters.
  • It burdens mental health systems that become tasked with addressing the housing and shelter needs of those admitted to the hospital.

“Involuntary hospitalization and outpatient care, with appropriate safeguards and practices to ensure procedural justice, have an important role in mental health systems,” Kerman and colleagues concluded. “However, the New York City policy oversteps these important boundaries and is not the answer to homelessness among individuals with serious mental illness. Instead, it is the latest form of displacement-based approaches to unsheltered homelessness.”

For related information, see the Psychiatric News article “M.D.s Call for Community Resources Amid Plans to Force Homeless Into Care.”

(Image: iStock/Melpomenem)

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