Involuntary Commitment and the Problem of Homelessness

The City University of New York’s College of Staten Island sits on historic grounds. Before 1987, the campus was the Willowbrook State Development Center, perhaps the nation’s best known and most reviled facility for adults and children with severe developmental disabilities. Its patients suffered from cerebral palsy, Down syndrome, seizure disorders, emotional and psychiatric disorders, learning impairments, and traumatic brain injuries.

The subject of a shocking 1972 exposé by reporter Geraldo Rivera, Willowbrook housed up to 6,200 individuals in conditions that Robert F. Kennedy, seven years earlier, likened to “a snake pit.” The then U.S. senator described patients “living in filth and dirt, their clothing in rags, in rooms less comfortable and cheerful than the cages in which we put animals in a zoo.”

The story of Willowbrook’s closure—a now-familiar tale of reform via litigation—has an exceptionally ambiguous ending. Its promises to the contrary, New York State failed to successfully integrate many of the patients into local communities. As Columbia professors David J. Rothman and Sheila M. Rothman observed in their classic 1984 study, Willowbrook Wars, the state government failed to create an effective and extensive network of community-based centers and halfway houses to better serve those with severe developmental disabilities. The inmates’ lawyers had more success in securing the patients’ right to live in the “least restrictive” environment than in actually meeting their clients’ needs. The judicial system, after ordering Willowbrook closed, largely washed its hands of the challenges of ensuring that current or future individuals received sufficient levels of care.

The problems proved even worse for those suffering from severe mental illness, many of whom, today, are unhoused and wind up in emergency wards, psychiatric wards or jails and prisons without adequate support. In many cases, the belief that antipsychotic medications like Thorazine would provide a sufficient substitute for intensive psychiatric care proved illusory. Today, a quarter of those in the Chicago and Los Angeles county jails and New York’s Rikers Island “have been diagnosed with a severe mental illness.”

No wonder that the Pulitzer Prize–winning historian of medicine David Oshinsky recently published an essay in The Wall Street Journal entitled “It’s Time to Bring Back Asylums.” The piece’s subtitle sums up the op-ed’s argument: “Recent cases of violence by the mentally ill highlight the need to reconsider a long-maligned institution that now offers a promising solution.”

As Oshinsky notes, “Surveys of those released from state asylums found that close to 30 percent were either homeless or had ‘no known address’ within six months of their discharge.” Today, he writes in highly charged words:

Oshinsky is not alone in calling on society to reconsider institutionalization of the severely mentally ill. The increased visibility of homeless encampments coupled with a number of highly publicized incidents of violence involving the unhoused mentally ill has led a number of urban politicians, including Mayors Eric Adams in New York and Ted Wheeler in Portland, Ore., to propose changes in civil commitment laws to give authorities more leeway to force those with severe mental illness into treatment.

Let me be clear: it is not the case that most of the unhoused suffer from psychiatric disorders—although it is clear that homelessness itself can contribute to mental illness. The standard estimate is that as many as a third of the unhoused suffer from a psychiatric or substance abuse disorder. Also, it is important to confront the many ethical and legal issues raised by the calls for involuntary psychiatric commitment and the reopening of congregate institutions for the severely mentally ill.

• When will forced psychiatric treatment or institutionalization be deemed appropriate—and by whom? What rubric will replace the current standard, when someone is a danger to her- or himself or others?
• How would government prevent any new institutions from becoming detention centers or human warehouses, recapitulating the horrors of the past?
• How will public policy ensure appropriate treatment and monitor patient care and progress?
• How will the new institutions be funded to ensure adequate care? Massachusetts’s Worcester Recovery Center, a national model, cost $300 million to build and spends $200,000 a year for each of its 300 patients.
• What kind of community supports, housing and other assistance would be provided after people’s release?

Here, I should note that in comparison to other postindustrial societies, the United States fares poorly. There are 120 psychiatric beds per 100,000 residents in Germany against just 30 per 100,000 residents in this country.

The proposed alternative to long-term, scaled institutional treatment was community mental health care. Opponents of congregate care called for supportive community services including various residential options, case management and proactive interventions. Some examples exist, but over all, the movement faded.

Why, we might ask, did the country back away from community-based care? You can find the answer in a recently published book by Matthew Smith, a historian of medicine who has previously written important studies of attention deficit hyperactivity disorder and food allergies.

The First Resort: The History of Social Psychiatry examines the path that this country ultimately decided not to follow

Following World War II, a new approach to severe mental illness gathered steam. Social psychiatry traced many mental illnesses to socioeconomic, sociocultural, epidemiological and environmental factors, rather than to biology or the kinds of neuroses emphasized by psychoanalysts. An alternative to earlier psychodynamic and neurological approaches, social psychiatry tended to de-emphasize pharmacological and somatic (like lobotomies and electroconvulsive shock) treatments and instead focused on what its proponents considered some of the root causes of mental health problems: poverty, social isolation and community disintegration. The best response, social psychiatry held, lay in community mental health centers, which were to engage in proactive prevention as well as clinical care.

In the end, social psychiatry, in Smith’s view, proved to be too academic. Although its research exposed the social and environmental factors that contributed to mental health problems and inspired state and federal governments to embrace the idea of community-based mental health services, it failed to spell out successful prevention and treatment strategies or explain how such centers could be established in resistant neighborhoods. By the 1980s, funding for community mental health clinics dwindled, replaced by a growing and misplaced faith in “miracle” drugs.

It’s conceivable that the heightened visibility of encampments of the unhoused will spur renewed interest in an updated version of social psychiatry. I, for one, hope so. For this is one instance in which common sense is correct: although mental illness cuts across class, racial, ethnic and gender lines, there are certain social conditions that do make individuals more vulnerable to various mental impairments and exacerbate existing disorders. Stable living arrangements, an intact support network and proactive therapeutic intervention can make a big difference.

Smith’s argument strikes me as persuasive: that we need to recognize the socioeconomic factors that contribute to severe psychiatric disorders and adopt a more holistic approach to treatment that recognizes the importance of the social as well as the neurological contributors to severe mental illness.

Unfortunately, if history holds any lessons, it is that policy makers, reflecting large segments of the public opinion, are less concerned with tackling and treating severe mental health conditions than in making the problem less visible as inexpensively as possible. There is also a temptation to blame the unhoused for their own plight, attributing this to drug addiction and a refusal to take medication—though the best studies suggest that most of the homeless do not have a psychiatric or substance abuse disorder. In addition, while many politicians talk a good game about community-based services, few are willing to adequately fund such services or challenge local neighborhoods to establish mental health clinics.

Teaching about homelessness and severe mental illness in college classrooms will not directly address these challenges. Nevertheless, I am convinced that teaching about these topics through an interdisciplinary lens can be profoundly valuable. Not only can such an approach contribute to empathy, but it can also help students question unexamined assumptions, better inform public understanding and social policy, and teach students to view complex and controversial issues through multiple perspectives: economic, historical, legal, psychological and sociological, among others.

Let me very briefly review some of the themes that a holistic approach to homelessness might tackle.

• Homelessness is not a recent development. As Kenneth L. Kusmer demonstrated in the first comprehensive study of homelessness, published in 2002, the homeless have been a significant presence in urban and rural areas in the United States for two centuries. Although the words that Americans have used to describe those who are homeless have changed—beggars, bums, hoboes, street people, tramps, vagabonds, vagrants or the wandering poor—various kinds of homelessness are not new. This society has long had the transitional homeless (left homeless as a result of the loss of a job, a divorce, an act of domestic violence, an illness or expulsion from a family home), the episodically homeless, the chronically homeless and the hidden homeless (who lack a home of their own and live with relatives or friends).
• The nature of homelessness has apparently changed over the past half century. In contrast to earlier stereotypes of white male bums congregating in skid row districts and living in single-room-occupancy hotels or lodging houses and hoboes traversing the countryside and intermittently engaging in various kinds of unskilled labor, the homeless today are increasingly unhoused and are apparently more likely than in the past to include large numbers of women, children, nonwhites and young LGBTQ+ people.
• Earlier approaches to homelessness have faded. In the early and mid-20th century, cities dealt with urban homelessness with jails and lockups, as well as single-room-occupancy hotels and municipal lodging houses located in “skid row” areas that, in many cases, were eliminated through 1950s and 1960s-era urban renewal projects. Vagrancy laws forced many of the homeless to take to the roads or rails. In more recent years, deplorable conditions in municipal shelters led many homeless persons to live, instead, on the street or in encampments.
• There is not one homogeneous homeless population, but many different homeless populations. It is difficult to generalize about the factors that contribute to homelessness because the causes vary widely.
• Far from being a group of people with distinctive characteristics, the unhoused share much in common with other low-income Americans, especially those who live in extreme poverty. The most striking difference is that they lack a network of support that can provide housing.

A key question that an interdisciplinary approach to the study of homelessness must address is why, despite various public policy initiatives, the number of unhoused people has risen, especially in certain East and West Coast cities. That requires a multifaceted approach that encompasses the circumstances of low-wage workers, the cost and availability of housing, the impact of welfare reform, and a host of other topics, including declining access to relatives or friends with whom the unhoused can share living accommodations, as well as the deinstitutionalization of the severely mentally ill and the failure to provide adequate community mental health care services.

A college education that fails to grapple with this society’s most pressing problems is neglecting a huge opportunity to motivate students, challenge entrenched myths and misconceptions, and demonstrate the power of focused expertise. Just as a history that ignores the present is antiquarianism, so too a curriculum that evades present-day challenges lacks seriousness and depth. Even as university researchers strive to address climate change, we should also tackle other problems that exist close to our own campuses.

Here’s my suggestion: provosts, deans and other campus stakeholders should identify a series of “grand challenges” and incentivize faculty to develop interdisciplinary clusters of courses that grapple with these challenges from multiple angles. I can think of few better ways to demonstrate the relevance, timeliness and power of a college education.