The Debate Surrounding Court-Ordered Mental Health Treatment for the Homeless

Mental illness is common within the homeless population. In fact, studies have shown that up to a third of unhoused individuals have a serious mental illness, including schizophrenia, depression, bipolar disorder, anxiety, and substance abuse disorders.

California Governor Gavin Newsom recently revealed his plan to create mental health courts in every county of his state—which has one of the largest homeless populations in the country. This would allow treatment for more homeless people with severe mental health and addiction disorders but it would also force some of them into care—a move that many homeless campaigners see as a civil rights violation. 

“Homeless people are more likely to have chronic mental illnesses like schizophrenia or bipolar disorder,” says Amy Morin, LCSW and psychotherapist. “They may also be more likely to have substance abuse issues.”

Homelessness on the Rise

While the federal COVID-19 relief had a positive impact on homelessness, homelessness in America remains a crisis. “On any given night, more than half a million people in America are experiencing homelessness,” says a spokesperson from the U.S. Department of Housing and Urban Development (HUD). 

Homelessness is rising faster for older adults and people with disabilities, and there are stark racial disparities in homelessness. “While Black Americans represent 12% of the general U.S. population, they represent 40% of the nation’s homeless population,” says the HUD spokesperson. “Plus, Native Americans are significantly overrepresented in the homeless population.”

"Homelessness is a major stressor which exacerbates a lot of mental illnesses," says Julian Lagoy, MD, a psychiatrist with Mindpath Health. However, Dr. Lagoy believes it is difficult to treat some of these mental illnesses in the homeless population because a lot of them have very low insight into their illness and may not think that they need care in the first place.

Newsom's Plan for California's Unhoused Population

Governor Newsom's plan will provide 65,000 people with housing placements, more than 300,000 people with housing stability, and focuses on those with the most acute needs, with at least 28,000 new beds and housing placements for those with behavioral health issues and seniors at the highest risk of homelessness.

The Community Assistance, Recovery and Empowerment (CARE) Court would give judges the power to order unhoused people into mental health programs.

“There’s no compassion stepping over people in the streets and sidewalks,” Newsom told reporters at a briefing at a mental health treatment facility in San Jose. “We could hold hands, have a candlelight vigil, talk about the way the world should be, or we could take some damn responsibility to implement our ideas and that’s what we’re doing differently here.”

While Newsom is stressing that his intention is not to round people up and lock them away, but rather to offer them a way to get court-ordered psychiatric treatment, medication and housing, (preferably before they are arrested), some mental health professionals have reservations.

"Many homeless people end up in jail, so on the surface mandating people into treatment sounds like it could prevent crime and homelessness," says Morin. "But in reality, there are problems with forcing people to get treatment for mental health issues and substance abuse problems against their will."

We might be taking away their freedom to choose what type of treatment they would like—medication, therapy, or other services, Morin explains. "No one wants to be forced to take medicine that can have serious side effects and complications," she says. "People tend to do best when they have some say in the treatment they receive."

A Collaborative Approach to Homelessness

A collective approach can often be effective in helping people get their needs met. "Offering case management services, for example, might connect people to the services they need," says Morin. "It's important to treat people as individuals and to recognize that services should be customized to meet each person's needs."

Dr. Lagoy believes the best approach would be to try to fight homelessness head-on rather than to try and treat the illnesses of people who are already homeless. "It is still imperative that we treat homeless people who have mental illness, but it is important to try and solve the problem of homelessness at large, which will have a greater effect of treating mental illness by reducing or even eradicating that stressor altogether," he says.

A HUD spokesperson says while there are a number of contributing factors to homelessness in the U.S, the single most important factor is the crisis of rental housing costs and the lack of access to affordable housing or rental assistance.

"While the rental housing crisis affects many millions of Americans, certain people who have greater barriers or vulnerabilities are at higher risk of becoming homeless: people with disabilities or behavioral health challenges, older adults, youth, people on fixed incomes, people who have extremely low-incomes, and people with poor credit or criminal histories," they say. "HUD is working tirelessly to ensure that every American has a stable home, and that means doing everything in our power to end homelessness through a Housing First approach which ensures additional needed voluntary supportive services alongside housing assistance."

This includes the evidence-based permanent supportive housing model, which combines affordable housing with wrap-around supportive services to meet the needs of people who have complex service needs (including people with serious mental illnesses), as well as rapid re-housing programs that provide time-limited rental assistance and housing navigation services.