Sydney Pattison is majoring in neuroscience with a minor in biology and is a 2022-23 health care ethics intern at the Markkula Center for Applied Ethics. Views are her own.
The United States is experiencing two major crises: mental health and homelessness. What happens when the two intersect?
In November 2022, New York City Mayor Eric Adams created an initiative intended to address both crises. The initiative allows the New York Police Department to take homeless individuals into custody for psychiatric evaluation if they appear to be mentally ill and a danger to themselves. Mayor Adams stated that committing these individuals to care, even if they are not a danger to others, is the city’s “moral obligation.”
In Portland, Oregon, Mayor Ted Wheeler wants to lower the standard required to involuntarily commit individuals for care. His goal is to make mental health care more accessible for the homeless population. Currently, Oregon law requires that an individual be a serious threat to themselves or others to meet the criteria for involuntary commitment.
The new initiative in New York City and the proposed alterations to laws in Oregon are significant deviations from standard involuntary commitment laws. While noble in theory, these policies have two major pitfalls. First, these new laws fail to address the current shortage of mental health care providers and subpar infrastructure. Second, they rely too heavily on the police, which may result in increased criminalization of the homeless and mentally ill.
Lack of Infrastructure and Mental Health Care Professionals
The United States lacks an adequate number of mental health providers and the infrastructure necessary to support the growing need for services, especially for individuals in need of long-term care. Lowering the standards for involuntary commitment will only add more demand to a strained system.
As of September 30, 2022, only 27.7% of the mental health care professional need was met nationally. By 2024, the U.S. is projected to have a shortage of 14,280 to 31,091 psychiatrists. Other mental health care professionals–like nurses, psychologists, social workers, and therapists–could also experience shortages in the coming years.
Not only does the United States lack mental health care providers, but it also lacks psychiatric hospitals and beds. Some of this shortage can be attributed to deinstitutionalization, the closing of public or private psychiatric hospitals in favor of care from families or community-based interventions.
Implementing new involuntary commitment policies while the mental health care system is in its current state could have disastrous consequences. Providers will become even more overworked. Hospitals will become overcrowded. Committed individuals will not receive the treatment they need and deserve. Policymakers will fail to deliver the mental health care they promised.
Criminalization of Homelessness and the Mentally Ill
These new mental health plans rely on the police to find and commit mentally ill and homeless individuals. This presents an additional set of negative outcomes. Previous implementations of similar laws had damaging consequences. In 2010, New York City’s Homeless Outreach Unit–a team designed to transition the homeless to shelters or other programs–arrested more than 2,000 people for petty crimes. Furthermore, the U.S. homeless population over-represents minorities. Together, these two realities pose a significant threat to justice, furthering the differential treatment of racial and ethnic minorities and lower socioeconomic classes, especially in the context of healthcare.
Rather than receiving the mental health care these programs intend to provide, and the care these individuals need, homeless people could be forced into an unjust cycle involving homelessness, incarceration, and hospitalization. These programs provide only temporary support, meaning that these individuals could end up back on the streets following a period of psychiatric hospitalization.
New York City and Oregon’s policies present clear failures. However, the mental health and homeless crisis in the United State must be addressed. California has instituted a new policy that, while far from perfect, better addresses the crisis at hand.
California CARE Act: A Case Study
Governor Gavin Newsom enacted the Community Assistance, Recovery, and Empowerment (CARE) Act, which could allow a judge to write treatment plans for individuals with a diagnosis of schizophrenia or other psychotic disorders. This program targets individuals who are most at risk of incarceration or homelessness–including those who are already homeless–because of their mental illness.
The CARE pathway involves five steps:
Referral
People with prior engagement with an individual, including family members, health care providers, and first responders, can refer that individual for care. The goal of referral is to avoid institutionalization and offer treatment to those with untreated psychotic disorders.
Clinical Evaluation
The CARE court decides if the person meets the CARE criteria; a clinical evaluation may be part of this determination. Legal counsel and, if desired, a voluntary supporter are appointed to the individual.
Care Plan
The individual receives a specific CARE plan, which may include behavioral treatment, medication, and housing; this plan is developed by the county behavioral health agency in collaboration with the individual, legal counsel, and the supporter, if applicable. The CARE plan is approved and in place for up to a year.
Support
The local behavioral health agency begins treatment with the individual. Throughout the first year, regular status hearings offer opportunities to update the care plan, share progress, and extend treatment another year, if necessary.
Success
After completing treatment, the individual “graduates” from the program. Though their CARE plan is complete, they are still eligible for ongoing treatment, support, and housing.
California’s CARE Act is different from involuntary commitment or hospitalization. The CARE Act aims to intervene before the situation escalates. In doing so, state hospitals and their providers will not face an influx of new patients. New court systems will be created specifically in support of the CARE Act. Mental health services will be provided through existing community health centers, even in the long term.
The CARE Act limits the potential for negative consequences due to law enforcement involvement. While first responders can refer individuals to care, CARE participants will be provided with both legal counsel and a support person to help guide their process and maintain their autonomy. Such representation will ensure that the individuals are treated with respect and justice, in a manner that will better their situation.
The California CARE Act better protects patient autonomy and offers more just treatment by limiting the involvement of law enforcement, unlike policies in New York and Oregon. However, the CARE Act could place additional stress on the county behavioral health centers. Because CARE plans will be developed and managed by county behavioral health services, centers will likely face similar challenges as those that could arise in New York City and Oregon, such as a lack of infrastructure and providers.
Looking Ahead
Mental health care in the United States is in dire straits. California’s CARE Act offers a promising opportunity to keep mental health care within the community, avoiding the cycle of incarceration and hospitalization that other interventions could initiate. Alterations to the mental health care system, especially involuntary care of vulnerable populations, must ensure each individual is treated with respect, maintains their autonomy, and receives the care they deserve. Such expectations are impossible to achieve without proper infrastructure and enough providers.
If policymakers truly want to fulfill their “moral obligation,” they must focus on expanding their mental health care systems to create facilities and programs that are conducive to respectful, holistic, and equitable care for all.