We can’t solve homelessness by institutionalizing people. Here’s why

One of the greatest challenges facing the United States is the number of residents who do not have a place to live, one of the most basic, foundational necessities for well-being.

In 2022, the Department of Housing and Urban Development counted 582,000 Americans experiencing homelessness. That’s roughly 1 in 556 people, a third of whom live in California.

There are myriad, conflicting narratives about what has caused the homelessness crisis and what will resolve it. Because so many unhoused people also live with severe mental health challenges, mental illness is often a part of their stories. An estimated one-third of people who are chronically unhoused live with a severe mental health condition, most often schizophrenia or bipolar disorder.

A Group Therapy reader sent us a question about this intersection of marginalization: “I would love to read a discussion about how we’re failing with the homeless population. When we still had mental institutions, homelessness wasn’t really a problem. Now we seem to just let people with severe mental problems wander the streets. I believe it would be kinder to house them in institutions for treatment. What do you think?”

I want to acknowledge that this question will inevitably bring up a lot for people, depending on your background and political positioning. My hope is to unpack it through a a lens of compassion and curiosity, and the assumption that the majority of us want to find a humane solution to the homelessness crisis — and not only because it is uncomfortable, frightening or inconvenient.

In this newsletter, we’ll briefly look at the history of deinstitutionalization in the U.S., and we’ll investigate the common assumption that mental illness is at the root of the homelessness crisis.

The history of institutionalization in the United States

The first American psychiatric hospital fully supported by public funds opened in 1833 in Worcester, Mass. This marked the beginning of a movement to create comfortable places where people could have their basic needs met while they received treatment. Proponents believed that those suffering from mental illness could find their way to recovery if treated kindly, and sought to do away the harsh restraints and long isolation periods of the past.

By the start of the 20th century, though, psychiatric hospitals — also known as asylums or state hospitals — were seriously overcrowded and underfunded. The number of patients living in these hospitals peaked in 1955 at more than half a million. Abuse of residents by doctors, nurses and attendants was rampant.

The decline of institutions spurred a second movement, this time toward dismantling state hospitals. Activists pushed to treat people with severe mental health challenges more humanely and, with the advent of antipsychotic medications, hospitals began to close their doors.

In 1963, the Community Mental Health Act shifted the responsibility of patients from the state to the federal government, and called for the creation of community mental health centers that would enable people with mental health challenges to stay in their own homes while receiving care.

Over the next decades, hundreds of thousands of former patients were sent back to their families, many of whom were unable to care for them. A quarter-million newly discharged patients ended up homeless or or incarcerated.

Only a handful of public psychiatric hospitals remain. Psychiatric care is now provided through short-term stays at general hospitals and outpatient services that range from full-time assisted living environments to clinics and doctor’s offices. The quality and availability of these services vary widely. Today, most inpatient treatment for severe mental health conditions happens in jails and prisons.

Liat Ben-Moshe, an assistant professor of criminology, law and justice at the University of Illinois Chicago, calls the deinstitutionalization movement “successful” because it did what it set out to do: close down public asylums.

But many former state hospital patients traded one site of incarceration for another, Ben-Moshe said.

“Now they might be in prison or living in a large group home,” she said, “where they also don’t get to make decisions about their lives.”

Resolving homelessness

For some, there’s a natural leap from historical facts to the belief that institutionalizing unhoused people with severe mental health issues is the rational answer.

“That’s the narrative that’s out there, for sure,” said Keris Myrick, a mental health advocate and former chief of peer and allied mental health professions for the L.A. County Department of Mental Health. “People come to this quick conclusion because there’s this misunderstanding of what happened at the time of deinstitutionalization.”

The rise of homelessness and deinstitutionalization did happen at the same time in the 1970s and ’80s. The number of unhoused people did swell in urban areas, in part because of state hospitals closing, experts told me. But that’s not the full story.

President Reagan’s administration implemented neo-liberal reforms in the ’80s that effectively gutted public housing programs, including Section 8. The cuts affected people with a variety of housing needs, not just those with mental health conditions.

“They did this to stimulate the production of rental housing, and believed that the private market would successfully address the needs of people who needed more support,” Myrick said. “These systems never really recovered, or kept pace with the need.”

By the time George W. Bush took office, the U.S. Department of Housing and Urban Development’s budget had been slashed almost 60%. There’s still not enough affordable housing stock to keep up with demand, especially as economic inequality has drastically widened over the past few decades. Experts cite lack of affordable housing as the top reason that people become homeless, even for people with mental health challenges.

The instability and stress of living in motels and cars and on the streets can also worsen existing mental illness or substance use. In some cases, it also creates it.

But the vast majority of people with severe mental illness aren’t homeless, and institutionalization wouldn’t address the larger structural problems that have created the homelessness crisis, Myrick said. Over and over again, lack of affordable housing has been cited as the top reason that people become homeless.

“Homelessness is not a medical condition that needs treatment,” Myrick said. “It’s a social infrastructure problem that needs transformation.”

What it’s like to be institutionalized

So far, we’ve talked about the practical aspects of the homelessness crisis. But what often gets lost in this conversation is what institutionalization does to people.

As I noted earlier, the institutionalization of unhoused and/or people with severe mental health differences takes two forms in the modern era: incarceration and hospitalization. Up to a third of those incarcerated have serious mental health conditions, a much higher rate than in the general population. Americans with mental illnesses are 10 times more likely to be incarcerated than they are to be hospitalized.

I’m going to focus on hospitalization here, though, because it’s one way to understand the experience of being held in a mental health facility against your will.

Some people voluntarily opt to be hospitalized, but many do not. In California, an adult who is experiencing a mental health crisis can be involuntarily detained for a 72-hour psychiatric hospitalization when a mental health professional or police deem them to be a danger to themselves or others.

Very often, those who are involuntarily committed are taken to the hospital by police. This is what happened to Myrick, who has experienced homelessness and was diagnosed with schizophrenia and obsessive-compulsive disorder.

“The first time it happened, police came to my house, wrangled me to the floor, and ripped off my red Doc Martens because they were possible ‘weapons.‘ They took me to a big general hospital where no one would introduce themselves to me or explain exactly what was going on,” she told me. “They were asking me to comply with things, like having my temperature taken, but I didn’t know who they were. I was confused and scared. Because I didn’t respond affirmatively, they called a code and I was held down by several men, sedated and strapped to a table.”

Myrick’s story is not an uncommon one. A recent Times investigation revealed that even though hospitals are forbidden under federal law from restraining psychiatric patients except to prevent them from harming themselves or others, L.A. General’s Augustus F. Hawkins Mental Health Center has reported a restraint rate more than 50 times higher than the national average for inpatient psychiatric facilities. For many, these incidents left a lasting mark.

Every time Myrick received suggestions to go to the hospital after that first time, she said no. “Why would I agree to that? That first hospitalization was to ensure I got my medication, but no one asked me about my goals, why I wanted to end my life.”

“When I hear statements about increasing beds, returning to institutionalization, I wonder if people understand that psych units are a very hard place to flourish,” Myrick went on. “It may help some people in the short term, but the trauma and longstanding effects don’t go away. They turn people away from wanting to seek care. I was so traumatized that I did not want anything to do anymore with the mental health system because it harmed me so.”

In October, California Gov. Gavin Newsom signed a series of bills that loosen long-standing rules about who can be involuntarily hospitalized. Advocates anticipate that the new legislation will lead to more people being placed in treatment facilities against their will.

Ben-Moshe argues that California is “going backward” in its effort to wrangle increasingly visible mental illness and homelessness. “A lot of us in the disability rights world saw this coming,” she said. “The conflation between housing insecurity and mental health is bringing this about. The income inequality and displacement and gentrification has excelled at such an exponential rate in California, but the fear the scapegoating of the homeless and people with mental health differences — that is not new.”

Advocates like Myrick argue that supporting people with severe mental health conditions must include the input of the people who are affected, and also provide respite for family members who often don’t have enough knowledge or resources to help. For decades, people with lived experience of mental illness have been working toward creative, humane solutions like peer support services.

“It’s really important to acknowledge that some people with mental health differences need more supports than they have, for sure,” Ben-Moshe said. “It’s also important to acknowledge that we shouldn’t be Karens about it. Meaning often times, people who are calling for the removal of people, whether it’s from streets or other places, are bystanders. We need to fight for better infrastructure and also understand what happens to people when they get picked up.”

. . .

I know this newsletter does little in the way of providing concrete answers, but I hope it pokes some holes in some widespread assumptions. As always, I’d love to hear your thoughts.

Until next week,

Laura

If what you learned today from these experts spoke to you or you’d like to tell us about your own experiences, please email us and let us know if it is OK to share your thoughts with the larger Group Therapy community. The email [email protected] gets right to our team.

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More perspectives on today’s topic & other resources

Decades after state institutions shut down, their history could shape the country’s approach to prisons, according to this piece by the the 19th. For people in the disability justice space, carceral facilities and disability have long been linked; disabled people currently represent about 40% of incarcerated people overall, and nearly half of incarcerated women, according to government data.

Other interesting stuff

As the number of teen suicides rises, school policies may be making things worse, according to a story by my colleague Sonja Sharp. This year, for the first time, the median age for teen suicide in Los Angeles County has dropped to 16 — the youngest ever. And as systems of care have withered, an old superstition has taken root: that talking about suicide would cause people in crisis to kill themselves.