The homeless population is reaching epic proportions in high-cost cities and is glowing in places where homelessness was never as prevalent. Although the reasons are many, the homeless are poor, often have uncontrolled substance abuse disorders or suffer from mental illness. Often the homeless have all the above. High rents exacerbate the above problems.
On an average night, according to the U.S. Department of Housing and Urban Development, close to 600,000 people in the country will be homeless—a figure seen by many as an undercount. More than 40% will be “unsheltered,” or “living in places not suitable for human habitation,” and about 20% will be dealing with severe mental illness.
Writing in The Wall Street Journal, David Oshinsky explains that today people who live out on the street were in years past sometimes involuntarily committed to asylums. The issue is again in the news due to some horrific crimes committed by homeless people with mental illness.
The ongoing saga of the severely mentally ill in America is stirring attention again in a sadly familiar way. In Los Angeles in early 2022, a 70-year-old nurse was murdered while waiting for a bus, and two days later a young graduate student was stabbed to death in an upscale furniture store where she worked. That same week in New York City, a 40-year-old financial analyst was pushed onto the subway tracks as a train was arriving, killing her instantly.
Experts disagree on the amount of crime attributable to the homeless. Advocates for unhoused people claim that their crimes are minor, loitering, public urination and mostly victimless offenses. Others argue there are significant violent crimes committed by the homeless (not to mention shoplifting, organized retail theft and breaking into cars).
Many of the homeless suffering from mental illness do not seek the care they need while on the streets; and prison is an expensive and unnecessary way to house and treat people who need housing and mental health care. Perhaps an age-old method, that began to diminish with the Kennedy Administration, could work: asylums.
Asylums were created for humane ends. The very term implies refuge for those in distress. The idea was to separate the insane, who were innocently afflicted, from the criminals and prostitutes who were then commonly referred to as the “unworthy poor.” Asylums were popular because they provided treatment in isolated settings, far from temptation, while relieving families of their most burdensome members.
But “insanity” in these years cast a very wide net. A typical asylum included patients who were suffering from alcoholism, dementia, depression and epilepsy, as well as such now defunct diagnoses as “lunacy” and “melancholia.” The usual stay was marked in years, not months, as evidenced by the rows of crosses in asylum graveyards.
Nearly a decade after President Kennedy signed the Community Mental Health Act, designed to end asylums, a federal court ruled involuntary commitment must be limited to extreme circumstances. Later the U.S. Supreme Court further tightened requirements. The Supreme Court decided it was not constitutional to deprive people of their liberty due to animosity and intolerance.
In addition to questions about whether the mentally ill homeless are a danger to others is the degree to which they are a danger to themselves. A related question is how much self-harm should a free society tolerate?
Unsurprisingly, the nation’s three largest mental health facilities are the Los Angeles County Jail, the Cook County Jail in Chicago, and Rikers Island in New York City. Approximately one quarter of their inmates have been diagnosed with a serious mental disorder.
Are there other options? Yes, but they’re expensive. Also, if the goal is to treat people (and treat them humanely), the yearly cost can be very high. Massachusetts spent about $55,000 per patient in 2015 and some facilities spent nearly four times that amount. Whichever version of the old asylum model they attempt to resurrect, public health officials and advocates for the homeless will face the twin obstacles of cost and image. Not mentioned in The Wall Street Journal essay is how to convince the mentally ill homeless to accept confinement in an institutions where street drugs are replaced by psychiatric drugs.