Why Are So Many Homeless People Mentally Ill?

One of the most disturbing aspects of the modern homelessness crisis is the number of clearly mentally ill people deteriorating on the street. It wasn’t always like this. In fact, 40 years ago, this sad state of affairs didn’t exist at all.

What is Serious Mental Illness?

The National Institute of Mental Health defines serious mental illness (SMI) as “a mental, behavioral, or emotional disorder resulting in serious functional impairment.” In 2015, there were an estimated 9.8 million adults aged 18 or older in the United States with SMI, representing 4.0% of all U.S. adults.

When it comes to homelessness and SMI, we’re really talking about three diseases — clinical depression, bipolar disorder, and schizophrenia.

Clinical Depression. Most people feel sad or low at some point in their lives, but clinical depression is having prolonged periods of a depressed mood and/or a loss of interest in normal activities and relationships. Symptoms might include almost daily: loss of energy, feelings of worthlessness, impaired concentration, indecisiveness, hypersomnia (excessive sleeping), or recurring thoughts of death or suicide.

On the street, clinical depression can look like people sleeping or sitting in the same place for months at a time. People can barely eat, hold a conversation, or maintain basic hygiene. Over the 10 years I have worked in this field, I have witnessed a clinically depressed man surrounded rat-infested trash at his campsite. Another man was unable to leave his campsite even as it flooded during a storm.

Bipolar Disorder. Formerly known as “manic depression”, Bipolar Disorder is characterized by extended periods of depression AND extended periods of “mania.” Mania is the opposite of depression. It can range from being “up,” elated, and energized to full blown delusions, such as the belief that one can achieve super human feats, or that one has transformed into a famous or powerful person. This distorted thinking can lead to outlandish, violent, or generally inappropriate behavior, and people can completely destroy their lives while in a manic state (e.g. spending all of their savings on erratic purchases or abandoning one’s family to engage in risky behavior).

In one of the communities where I have worked, we had a woman who would routinely walk into businesses in our main commercial area during manic episodes and scream at customers. At other times, she would setup lawn chairs or use golf clubs in the middle of a public sidewalk.

Schizophrenia. Schizophrenia is a long-term breakdown in the relationship between thought, emotion, and behavior, which can lead to faulty perception, hallucinations, paranoia, and delusions of grandeur. In the fantastic book Street Crazy, Dr. Stephen Seager describes schizophrenia as more than a disease — it is a form of torture. Instead of actually killing you, schizophrenia can cause financial death, employment death, social death, and perhaps most sadly of all, personality and intellectual death. After onset, schizophrenia can cause a person’s IQ to drop by as much as 45 points.

Research has shown there are really two types of schizophrenia. One type of schizophrenic hears voices, has paranoid and disorganized thoughts, but they retain their basic — albeit odd and aloof — personality. These folks do well on medications, and with adequate support, and they can lead a fairly normal life. By comparison, the second type of schizophrenic has hardcore, psychotic symptoms. These individuals might be found wearing four layers of ragged clothing on a hot day, they might be found staring blankly and babbling, or they might make outlandish claims about being Jesus or being stalked by the CIA. For these people, brain scans reveal significant structural damage to the brain, similar to what happens with dementia.

From Torture to Compassion

Despite what we know now about mental illness, for thousands of years it was profoundly misunderstood. Often thought to be witchcraft, demonic possession, or simply moral shortcomings, these misdiagnoses justified a variety of inhumane practices.

• In 30 AD, the Roman doctor Celsus argued that philosophy and personal strength were the key to recovery. To that end, he advocated treatments ranging from the wearing of amulets to physical torture.
• In 1483 the Pope sanctioned Malleus Maleficarum (or “Witches Hammer”), which blamed the mentally ill for the Bubonic Plague and justified burning them at the stake. “Trephining” was also common in the middle ages. It was the practice of drilling a hole in someone’s head so evil spirits could leave.
• In Street Crazy, Dr. Seager describes how in the 1700s doctors often thought physical and mental health were connected. As a result, mentally ill patients were submerged in ice water baths, placed in physical restraints, and locked away in isolation.

At the same time, there have also been glimmers of hope for more compassionate care:

• The first mental health “asylums” were built in ancient Egypt and Greece. They included boat rides on the Nile and trips to concerts. Asylums were originally seen as havens, shelters, or retreats. Egyptians tried to engage people in society through social activities like dancing and concerts.
• For centuries residents of Geel, Belgium, have hosted severely mentally ill people in their homes, simply accepting them as they are.

Dorothea Dix

Dorothea Dix was one of the earliest mental health reformers in the United States. In 1840, Dix initiated a statewide investigation into the care provided for the mentally ill in Massachusetts. Back then, towns contracted with local individuals to care for mentally ill people who could not care for themselves. Unregulated and underfunded, this system resulted in widespread abuse. Many vulnerable people ended up on the street or in jail.

In a report to the Massachusetts State Legislature, Dix said, “I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth, in cages, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience.”

These grim findings spurred action. The State of Massachusetts passed a bill to expand the State’s mental hospital in Worcester. Building on this victory, Dix toured states all across the country documenting the living conditions of the mentally ill living in America’s prisons.

In the end, Dix played an instrumental role in the founding or expansion of more than 30 state hospitals for the treatment of the mentally ill. She was a leading figure in national and international movements that challenged the idea that people with mental disturbances could not be cured or helped, and she was a staunch critic of cruel and neglectful practices, such as caging, incarceration without clothing, and painful physical restraint.

The Forgotten

In some ways the state hospital system was too successful. People with mental illness had a new place for treatment, and for almost 80 years, Americans gradually forgot that untreated SMI had even been such a significant, societal problem. Of course, any system that skirts public accountability for almost 80 years is bound to develop problems, and that’s exactly what happened.

After World War II, increased scrutiny and accountability descended on the mental health system, and a grim picture emerged. In 1955, with 580,000 Americans living in these facilities, Congress and President Eisenhower passed the Mental Health Study Act, which created a joint commission to investigate. Greer Williams, a prominent psychiatrist and writer, was the editor of the commission’s final report. In July of 1961 he told The Atlantic:

Comparatively few of the 277 state hospitals — probably no more than 20% — have actively participated in the modern therapeutic trend toward humane, healing hospitals and clinics of easy access and easy exit, instead of locked, barred, prison-like depositories of alienated and rejected human beings … [the typical state hospital] does a good job of keeping patients physically alive and mentally sick.

As public support for state hospitals continued to erode, exemplified by books like One Flew Over the Cuckoo’s Nest (1962), with its graphic depictions of electroconvulsive therapy and unsympathetic portrayals of mental health workers, this period also witnessed progress. New anti-psychotic medications emerged, such as Thorazine. Although the effects varied from person to person, for the first time many patients with SMI could be reliably treated beyond the hospital walls.

As a result of these developments, when John F. Kennedy became president in 1961, a new vision for mental health treatment was emerging. “We must move from the outmoded use of distant custodial institutions to the concept of community-centered agencies.” To replace asylums, JFK envisioned a national network of community-based mental health centers, equipped to provide “a coordinated range of timely diagnostic, health, educational, training, rehabilitation, employment, welfare, and legal protection services.” The “Community Mental Health Centers Act” (CMHCA) ended up being the last piece of legislation JFK signed into law before he was assassinated in 1963.

The Unintended Consequences of Deinstitutionalization

The shift that resulted from the community mental health movement is often called “deinstitutionalization”. If you were to evaluate the success of deinstitutionalization by measuring the clearing out of state hospitals, it was a resounding success. Between 1955 and 1998, the populations in state and county mental health hospitals dropped from approximately 558,000 to fewer than 60,000. Per capita, today the US only has 6% of the mental health bed capacity that it had in 1955. This might suggest community-based mental health treatment is alive and well, but as evidenced by sad scenes in the homeless community, that’s not what actually happened.

#1 Medicare and Medicaid

Before deinstitutionalization, state hospitals actually served a variety of people, and surprisingly, most people experiencing SMI were being treated and returned home. By comparison, long-term neglect was much more common among senile elderly people and people with incurable, degenerative neurological conditions (epilepsy, ALS, multiple sclerosis, Parkinson’s), who were also warehoused in these facilities.

In 1965, just two years after JFK was assassinated, President Johnson signed Medicare into law. With guaranteed medical insurance regardless of income, elderly patients could finally move out of state hospitals and into nursing homes. In 1966 President Johnson signed Medicaid into law, which provided federal funding for vulnerable people regardless of age. This allowed people with neurological disorders to also move to nursing facilities. In just 3 years, state hospital populations dropped by 50%.

This was great news for a lot of people but not folks with SMI. Local community mental health centers didn’t actually takeover care for the seriously mentally ill. Instead, newly created community mental health centers provided easier access for people with anxiety disorders, mild depression, and substance use disorders — problems previously unaddressed by public funding and services. Unlike the state hospitals, these centers couldn’t handle the extreme behavior of people with SMI — they didn’t keep appointments, refused medications, and exhibited active psychosis among other challenges. If there were “easier to serve” people, why attempt to treat those who actively resisted treatment and/or denied they were even ill?

#2 Defunding Mental Health Services

Even though the 1960s witnessed massive investment in publicly-funded healthcare through Medicaid and Medicare, the Community Mental Health Act of 1963 was almost immediately gutted of its major funding provisions. The American Medical Association opposed including funds for personnel, and in the final bill nothing was set aside for staffing (the entire community-based treatment model was premised on staffing).

In the last year of his presidency, Jimmy Carter signed the Mental Health Systems Act (MHSA) of 1980, which provided more grant funding directly to community mental health centers; however, even after John Hinkley, Jr. — a man suffering from an untreated psychotic disorder — attempted to assassinate President Reagan in March of 1981, Reagan went on to repeal most of MHSA later that same year.

There were glimmers of hope for the mental health system in the 1990s and 2000s. President George H.W. Bush proclaimed the 1990s as the “Decade of the Brain” to focus attention on the benefits of brain research. He also signed the Americans with Disabilities Act (ADA), a landmark bill prohibiting discrimination against individuals with disabilities — including people living with mental illness. President Bill Clinton signed the first limited mental health parity law: the Mental Health Parity Act (MHPA) to begin addressing disparities in coverage between physical illness and mental illness. In 2008 President George W. Bush signed the Paul Wellstone and Pete Domenici Mental Health Parity and Addictions Equity Act.

Sadly, the Great Recession reversed much of this progress. Between 2009 and 2012, America’s 50 state legislatures cut a total of nearly $4.5 billion in services for the mentally ill, even as patient intakes increased by nearly 10% during the height of the economic crisis.

These downward trends have only continued with President Trump. Following the murders of 17 young people at Marjory Stoneman Douglas High School in Florida in 2017, President Trump remarked that there were, “So many signs that the Florida shooter was mentally disturbed, even expelled from school for bad and erratic behavior … and classmates knew he was a big problem.” Regardless, a few months later, the President’s budget proposed cutting the Substance Abuse and Mental Health Administration by $665 million and the National Institute of Mental Health by $500 million.

#3 Expanding Civil Liberties

It might sound odd to describe an expansion of civil liberties as a bad thing, but in the context of serious of mental illness, some reforms have meant that the sickest of the sick are unable to receive the treatment they desperately need precisely because they are so symptomatic.

When people are “institutionalized” or “committed”, they are held involuntarily for treatment. There are two legal ideas that enable this practice:

• “Parens Patriae” is a legal idea harkening back to medieval English kings whereby the monarch is empowered to be a “substitute parent” for those who can’t care for themselves.
• “Police Powers” grants the government the right to protect society from dangerous individuals.

In the 1950s it was clear that the commitment process, like state hospitals, had also been wildly abused. Family members were colluding with doctors to lock away spouses and elderly relatives, and patients were often subjected to treatment against their will. Building on the momentum of the Civil Rights Movement in protecting individuals’ civil liberties and right to due process, in 1969 California passed the “Lanterman-Petris-Short” Act. In a few short years, the “LPS Commitment Process” became the model law for almost every state in the country. The LPS Act created strict new standards for involuntary holds and, in the process, essentially moved oversight away from healthcare providers and over to the criminal justice system. To this day, to be placed on an involuntary hold, a judge must determine that someone is:

• An imminent danger to themselves (suicidal)
• An imminent danger to others (homicidal)
• Gravely disabled (unable to provide food, clothing, or shelter)

While this is all well and good, over time courts have interpreted these types of laws in an increasingly expansive way. In 1975 in Donaldson vs. O’Connor, the US Supreme Court not only upheld the LPS concept, it went a step further to say no one can be hospitalized involuntarily if that person can simply “survive” in the community. In 1979 in Reise v. St. Mary’s in California, the court gave mentally ill people the right to refuse treatment. The California Supreme Court has also ruled that past behavior patterns may not be weighed as evidence; instead, involuntary holds must be based on an “imminent” danger.

In Street Crazy, Dr. Seager writes about his work in a psychiatric emergency unit in Los Angeles, during which time he witnessed many extreme and graphic examples of the dysfunction made possible by our current laws and legal precedents.

Pamela grew up in Maryland. After a relatively uneventful childhood, as a young woman Pamela had a violent, psychotic break during which she stabbed her mother 47 times. At her trial Pamela indicated voices had compelled the attack, and she was sent to a state hospital. Amazingly, she was released after just one year. With her new freedom she got on a bus and headed to Los Angeles. After arriving in LA, Pamela’s schizophrenia began to encourage self-mutilation, and over the next couple years Pamela cut off the tips of all of her fingers, toes, nose, and ears. This self-endangerment landed her in psych emergency 49 times. Every time Pamela started taking medication, her condition improved, and she was released. Once Pamela felt partially well again, she stopped taking her medication. On that 49th visit, Pamela had gouged out one of her eyes.

The Boomerang to Today

By the early 1980s (not coincidentally the beginning of the modern homelessness crisis), it was apparent that something had gone terribly wrong:

• “The policy that led to the release of most of the nation’s mentally ill patients from the hospital to the community is now widely regarded as a major failure,” declared The New York Times in 1984.
• “States proved more enthusiastic about emptying the old facilities than about providing new ones,” the Chicago Tribune noted in 1989. “Many patients went from straitjackets to steam grates.”
• Frank Lanterman himself, co-author of the LPS Act, regretted how the law had evolved. “I wanted the law to help the mentally ill,” he said. “I never meant for it to prevent those who need care from receiving it.”

In a sad sign of how far our mental health system has fallen, we have now boomeranged back to the ante-bellum paradigm that motivated Dorothea Dix 170 years ago. It is now believed that a third to half of all inmates in the US have a mental illness. That’s 400,000 people. If you throw in probation, parole, and any contact with the criminal justice system at all — it’s 1,000,000 people. The three largest psychiatric centers in the United States are jails: Rikers Island, Cook County and Los Angeles County. The National Alliance on Mental Illness estimates that between 25 and 40 percent of all mentally ill Americans will be jailed or incarcerated at some point in their lives.

Like they were in the 1800s, jails continue to be a terrible place for people with mental health issues. In Insane, Elissa Roth visited prisons across the country, observing mentally ill people without access to medication, constantly surrounded by loud noises and sounds, in tight confined spaces, sleep deprived, and often in isolation. Mentally ill inmates fail to understand the rules and punishment they’re expected to follow, which results in the exact opposite behavior of what correction officers want — paranoia and noncompliance

This depressing state of affairs was not inevitable. Our current mental health system is the result of decades of bad policy and underinvestment.