How homelessness can be viewed as a symptom of mental illness

With the backdrop of the migrant crisis, shelter turnovers are at their shortest in a decade, only followed by a two-decade record of unhoused individuals sleeping on streets and subways. To ease this stressed system, one promising solution may lie in quickly moving unhoused individuals into permanent supportive housing – connecting them to wraparound services under one roof. 

Yet, according to front-line experts closest to unhoused adults, persuading individuals to leave the streets into housing poses unexpected challenges that highlight key systemic shortcomings. Instead of forcefully removing people off streets, experts recommend outreach-based approaches that prioritize building relationships that create natural pathways to housing and continuous care. 

While a sizable portion of unhoused single adults struggle with untreated mental health conditions and substance use disorders, most are reluctant to re-enter the supporting housing system, due to previously poor experiences in foster care, involuntary displacement or mistreatment from health care providers.

“Oftentimes, people with severe mental illness, especially those experiencing poverty and poor access to care, are actually encountering the psychiatric and health care system in emergency rooms, or under coercive care where they might be brought in by EMS or police. If they're hospitalized, it's oftentimes involuntary hospitalization,” said Anthony Carino, director of psychology at the Center for Urban Community Services. 

As many homeless adults base their perceptions on previous coercive encounters, this leads to a general sense of disaffiliation and mistrust of health and housing systems. Additionally, as supportive and permanent housing options require strict mental health thresholds, many chronically homeless adults fail to qualify, resulting in worsening conditions. 

“When there's a limited housing stock of accessible, affordable housing, folks who tend to not access housing tend to be people with disabilities, such as severe mental illness,” said Carino. “We also see that there are times that untreated mental health conditions actually lead to the lack of accessing housing in and of itself, where the symptoms are barriers for people.”

In order to reach this vulnerable population, experts argue for outreach-intensive approaches that focus on bringing direct medical care to unhoused individuals. Last year, The Center placed 377 people into housing, with street outreach teams serving 431 people, mostly male, with 203 individuals being of Black or African American descent. From street medicine teams equipped to treat those with high behavioral health risk to their community, to psychiatric outreach teams who regularly meet unhoused individuals in streets and subways – experts argue that meaningful relationship building is key to helping unhoused individuals tackle harmful misconceptions and seek care. 

“We acknowledge that people are coming from a place of mistrust, that’s protective and associated with their survival,” Carino explained. “So we create a space and a therapeutic relationship that's empowering to the person, where they have a safe space to express their needs and goals and to get psychiatric care that's on their terms, and also highly effective. And that psychiatric care is connected to a trusting relationship, with housing and benefits.”

Shortages of licensed psychiatrists and social workers who are willing to patiently foster relationships with unhoused adults –  tends to plague efforts toward widespread change, according to Van Yu, the Center’s chief medical officer. 

“You have to gain people's trust and then nurture relationships. We have a saying that ‘relationship is treatment.’ So how do you get a person's trust? That requires a lot of flexibility and creativity, like visiting a person repeatedly, even if they tell you to go away.” 

Yu said this process can vary tremendously from case to case, from a couple weeks to six months – often including weekly informal checkups, treatments of physical injuries and more. 

“There's a high level of flexibility. Most of the folks that we serve are not well-treated by traditional outpatient clinics,” Carino said. “So our care tends to be highly flexible, highly accessible, and goes to where the person is, because this population doesn't respond well to traditional clinic-based approaches.”

Ultimately, by nurturing such relationships, CUCS’ outreach teams serve as pipelines that connect homeless adults to treatment facilities and permanent housing –  both of which are in short supply. 

“What we see is that chronic street homelessness decreases when the supportive housing units increase. […] Supportive housing with accessible psychiatric primary care, and case management services works,” Carino continued. “What we really need to do is increase and ramp up the scale, with what’s really effective. People do get better and improve. Once folks get to permanent supportive housing, more than 90% of them will stay.”

According to experts, widespread closures of the city’s inpatient psychiatric beds are hurting the quality of treatment afforded to unhoused adults, in addition to their chances of being permanently housed.

“I think homelessness can be conceptualized as a symptom of mental illness,” said Yu. “While it is not the case that every person who is homeless is living with a mental illness—mental illness and substance use is a vulnerability that contributes to homelessness.”