A Rationale and Plan for Addressing Severe Behavioral Health Disorders in the Homeless

---

Issue Areas

---

Serious mental illnesses are chronic, recurring conditions that share a common challenge among those affected by them: a lack of awareness that one is unwell. These diseases, such as schizophrenia, schizoaffective disorder, and severe bipolar disorder, as well as severe substance use disorders, debilitate an individual so substantially that they often lose awareness of the deleterious nature of their symptoms. This lack of awareness leads patients to repeatedly fail to adhere to recommended treatment and, in the most severe cases, experience a steady downward spiral of homelessness, involuntary hospitalization, incarceration, and early death.

In the United States, the approach to people with these illnesses often involves both the mental healthcare system and the justice system. Individuals with illness severity that impairs their decisional capacity and ability to think rationally often engage in criminal activity, whether it be nuisance infractions such as criminal trespass or more serious crimes where innocent people are harmed in the throes of paranoid delusions. These severely mentally ill individuals will be involuntarily hospitalized through the legal system so that their mental illness can be treated. This process is known as civil commitment.

Civil commitment is frequently utilized to compel cooperation with treatment, including the use of medications meant to extinguish the hallucinations and delusions. However, the sad reality is that current civil commitment laws and competency restoration statutes are for short periods of time—days to several months.

Upon expiration of civil commitment periods or when an affected person’s symptoms resolve to a point at which they petition the court to release them from compulsory treatment, non-adherence often rapidly follows. The result is what has been termed the revolving door of treatment—relapse to psychosis, to the street, to incarceration.

“Advocates” for many years have elevated the quest to preserve the mentally ill person’s ‘civil rights,’ meaning the right to refuse treatment at the expense of others and of communities at large. Contrary to the claims that this is the ‘humane’ approach that respects civil rights, we know that the longer the duration of untreated psychosis, the more severe and debilitating these serious mental illnesses become, doing substantial harm to the person with severe mental illness.

In recent years, numerous research studies have examined outcomes associated with nonadherence to prescribed medications and untreated psychosis. These studies chronicle the severe adverse effects of medication noncompliance and recurrent psychosis for extended time periods, which include brain changes that impair thinking and reasoning. More importantly, symptoms become more resistant to antipsychotic treatment, leading to the need for higher medication doses and increased side effects. Further, increased social withdrawal and loss of motivation, in some with histories of violent behavior, increases in these behaviors, increased hospitalizations, and early death often by suicide have all been associated with treatment noncompliance. To sum it up, in the name of liberty, we are condemning those with serious mental illness to incapacitation, worsened illness, and early death.

Given the accumulating knowledge regarding the course of mental illnesses with psychosis as a prominent component, it is long past time that we work quickly with partnerships between the medical community and the judicial system to bring intensive and ongoing psychiatric care to our most ill.

The Executive Order “Ending Crime and Disorder on America’s Streets,” encourages actions that will lead to the establishment of mental healthcare resources and housing, in cooperation with and support from the judicial system. Here’s how we can do this:

1. Define what constitutes serious mental illness and severe substance use disorders that will require compelled treatment. Expand civil commitment laws to extend treatment requirements for those most severely ill from months to years.
2. Make resources available at the state level with assistance from federal agencies to address mental health care, physical healthcare, and housing simultaneously using a multidisciplinary team approach and community supports. Utilize opioid settlement funds to help to establish necessary services not currently available.
3. Assure continuity of residential treatment programs through a robust vocational rehabilitation program that teaches skills, serves the community, and generates income back to the program to continue treatment services while also providing a means of gainful employment to the individual upon completion of treatment.
4. Lift the IMD exclusion to provide long-term inpatient care for those with the most severe and refractory illness who have not been able to be safely maintained in the community.
5. Maintain psychiatric services for the most severely ill, penalizing facilities with a reduction in reimbursements should they fail to continue effective medication regimens, meet ongoing treatment needs, or renew civil commitment. Require court appearance to end a civil commitment in addition to the current standard of court appearance to establish and continue civil commitment.

Each state should develop its plan based on the needs of its population and the resources available within its jurisdiction. These new policies will offer a path towards stability and a higher quality of life for the most vulnerable Americans for the first time in decades.