When I was working for Metro government, I often had conversations with Nashvillians from all backgrounds about solutions to homelessness. People were understandably and justifiably upset about people camping out in their neighborhoods or in front of their businesses.
While the majority of people experiencing homelessness do not pose any threats, as the neighbors themselves told me, some of the ones with mental illness and/or substance use may eventually start to display disruptive behaviors.
I received similar feedback from some people living in encampments where they formed a community over time. I recall one particular conversation where a veteran who had set up a small camp with his buddy pulled me aside and asked me if I could help remove a tent across the path from them, whose occupants he felt disturbed the peace.
So today, I am attempting to tackle an issue that neighbors have increasingly demanded from me when I was still working in Metro government, namely that I pursue forced treatment as a solution to homelessness.
I do not believe in it and see it as the usual Band-Aid approach. My response to that remains the same. We have overused Band-Aids. They don’t stick any more.
Now, before I get started, let me be clear. I do not view neighbors who want quick solutions as villains in these discussions. They care. They want solutions. They want people they see living outdoors in their neighborhoods to have a chance to do better and flourish. They want to improve their own quality of life together with the quality of life of the people they don’t know how to help.
But forcing people into treatment, especially via jail, prison or other institutions, is not the answer to homelessness. It is a shortcut for avoiding the investment of time, relationship building, and cost of housing with wraparound support services including recovery services to address mental health and substance use. Those approaches, in fact, would end homelessness — and they are still less costly than forced treatment.
Forced treatment is such a big issue for me that I felt I could not do it justice on my own. Therefore, I spoke with Rob Wipond, the author of Your Consent Is Not Required: The Rise in Psychiatric Detentions, Forced Treatment, and Abusive Guardianships.
Here is an excerpt from our recent conversation. Responses have been shortened for brevity.
Give us a synopsis of what your book is about.
There are two levels that the book develops on. One is people’s personal experiences of what it’s like to be forcibly committed, to have these kinds of forced psychiatric interventions, police interventions, and I really explore all the different places in our communities that that is happening.
And then I look at and take apart the dominant narrative, [which is that] in the 1950s we started closing asylums and all those people ended up on the streets homeless or in prisons. That’s why we have the problems we have today in the streets, so we need to rebuild these institutions. What I show in the book is that this narrative is actually a very deliberately misleading story.
Essentially, all the studies we have that followed the closures showed that all of those people found housing. A lot of funding has gone into building smaller institutions of different kinds, including group homes, nursing homes, different types of places. I am not saying these places are necessarily good, but they were designed to replace the role of asylums.
At the same time that’s been happening, actually the rates of involuntary commitments were going up quite dramatically since about the 1980s and ‘90s. So, we have more and more beds available for putting [people away] long-term. And that narrative is not being told.
Most of what we’re debating right now around these issues is not true, and so we need to get the truth out first and then continue the discussion and debate. That’s what the book does.
As neighbors have become more savvy in organizing against visible homelessness, the pressure on local politicians has increased to implement solutions at a faster pace. I had many conversations with really caring and well-meaning neighbors who made it clear that they had lost their patience. They want public spaces back. And their suggestion was to arrest people & make them get the services they need. In your view, how should the local government respond to these demands?
Well, local governments are bearing the brunt of the problems and have the least power or responsibility really for causing them. So these problems are largely the result of federal and state governments that have increasingly gotten out of providing subsidized housing, public housing. They have been deregulating housing markets in different ways; private equity has moved into the housing market; banks and credit unions invest heavily in the housing market; so we’ve seen housing prices going up along with the rental costs, and wages — particularly lower- and middle-income wages — have not been increasing. And so we have more extensive poverty.
This is largely the result of both massive market forces and high-level governments not taking responsibility and not really trying to attack these problems. In fact, they continue to make them worse because they don’t have to deal with them.
The people who have to deal with them are local people. That’s where homelessness appears. And so local governments are stuck with this, but they don’t have the financial resources to deal with it in most cases.
So [local governments] should be better organized, and they should be campaigning up the hierarchy and demanding that state governments respond to this better, demanding that the federal government do something about it.
Unfortunately, when they do that, they tend to focus on things like, “Hey, let’s strengthen mental health laws.” Instead of saying, “you need to get back in the business of housing.”
Basically, this is what’s going on. So we have to address that problem. We can’t just ignore it. But … if you’re trying to solve a problem without the resources to solve it, you often end up proposing really stupid solutions.
And that’s what’s going on right now across the country. We see local governments often feeling pressured into proposing not very good solutions, and they are actually very costly. Let’s be clear about that.
Putting someone into forced treatment is extremely costly. I’m talking $2,000-$3,000 per day. Far more costly than imprisonment, really, which is extremely costly already.
It makes no sense financially. If those governments would get together and collaborate, they’d say, housing is cheaper, even supportive housing is cheaper.
Basically, you seem to advocate for governments to focus on housing first. Unfortunately I have seen too many programs, including in Nashville, too often to only focus on the housing part and then move on or offer only limited services. What about the treatment aspect?
Housing First does work for some people, like, “Give me the housing and I’m good.” But a lot of people, if they’ve been struggling, they have real issues, they need a little more than that.
Housing is great. It’s a first step, but they need voluntary supports of different kinds. For some people that may be some sort of mental health supports, but for a lot people it’s things like just day-to-day practical supports like help me get shopping, help me relearn what it means to be living in my own place and make sure I pay my rent on time and whatever these things are that I need to do because I’ve been homeless for so long.
We’ve seen study after study showing us that even providing those kinds of robust, voluntary supports is much cheaper than giving people psychiatric hospitalization.
I wanted to unpack two issues with you. One is treatment when someone has committed a crime like a violent offense, and treatment when folks are simply unhoused and considered a nuisance because they are visible. They may be arrested multiple times for trespassing, public intoxication, illegal camping or other quality of life issues. Why is it important to distinguish between them?
We need to separate these discussions out, because they’re in so many ways unrelated to each other. This entire set of laws and processes for what we call forensic criminal psychiatric commitment, if I do something violent and I plead not guilty by reason of insanity or I’m declared incompetent to stand trial, there is a whole set of criminal laws that address that situation. And that situation is not great. There are a lot of problems in those laws and processes people need to know about and discuss the result.
But they’re completely different than the whole set of laws that govern what we call civil commitment, which are things like, “How do I help my over-anxious child who won’t go to school?” Or “How do I help my depressed elderly parent who doesn’t get out of bed anymore?”
Sometimes the civil commitment system is supposed to be a helping system. Now, it is also important to understand that these systems are overlapping increasingly because what’s happening is, as you’ve identified particularly with homeless people, governments are trying to control them in any way they can. And ordinary people … are calling 911, they might have the intention of helping the person or they might not. They might just want to get the person in trouble.
Either way, they call 911, the police show up, and these people get arrested for things like trespassing. So it’s not a criminal offense. They’re not dangerous. They’re just on the street. They’re annoying to someone. They’re a nuisance of some kind because they’re stuck living in the street.
These kinds of people are being much more aggressively policed these days in most cities across North America, and they’re either being taken to jail, or they’re being taken to a psychiatric hospital or an emergency room. And then things just start to play out from there.
This system is not working. It’s becoming increasingly aggressive and also happens as the people get thrown into the hospital again because they’re not actually meeting the criteria for civil commitment. They’re just a nuisance, and they’re not really supposed to be in jail either.
So what’s happening then is judges are increasingly thinking they’re doing something good, and they’re just declaring these people incompetent because that’s a pretty broad term. They’re trying to get these people help because maybe they are struggling in some way.
That system is now increasingly backed up and people are sitting in a state penitentiary or a state hospital, sometimes for years, just waiting for their day in court. And it’s chaotic. It’s ridiculous. It’s out of control. And again, because people aren’t being honest and clear about what’s really happening in these systems — the data is not very well collected — we’re not having clear public discussions about what we’re trying to do here, [about] what we think we can achieve as a result. This is just getting worse and worse. That’s why you hear about the competency crisis.
I want to highlight that my research is finding that this is unique to America. Canada does not have that problem. UK does not have this problem. Something is happening in America where these people are being much more aggressively policed and declared incompetent at rates that this is just not happening in any other country.
So either you have to say people in America are crazier than everywhere else, or you’re going to say people in America are being more aggressively policed in the streets, and for some reason judges and prosecutors are falling into the habit of simply declaring them incompetent because they think that’s a solution. And other countries realize it’s not a solution and just aren’t doing it. So this is something we need to be talking about more, too.
At this point, we shifted our conversation to talk about families that are desperate to help their loved ones who suffer from mental illness but refuse any suggestion to access treatment.
In particular, I shared with Wipond my personal experience. My husband is a Veteran who after multiple deployments has been diagnosed with severe PTSD. At one point, his depression got so bad that he suffered an acute mental health crisis, and I had to make a decision to either call 911 and have him forcibly committed or monitor the situation on my own as best as I could, giving him the options of reaching out for help.
I decided to make sure he had immediate access to a crisis lifeline, in this case 988, and monitor the situation.
Wipond and I then talked about these individualized decisions, and the lack of options that render family members like me feeling helpless. It’s easier to call police on a person we see on the street and feel like we’re helping them than being faced with the decision to make that call when it is one’s own family member.
My decision essentially was based on the knowledge that any forced treatment would reduce the chance of my husband ever getting the help he needed voluntarily, which was necessary for him to stick with it and learn to manage his mental health.
It turns out, I was right. He is now doing much better. But another theme we often overlook is the fact that mental illness tears families apart. I myself was at a point a few years ago where I had to seriously think about my own future, and whether or how I chose my partner’s mental health to affect the rest of my life.
But locking him up and trying to force him into treatment was not the choice that I believed in.