(I know it’s been a minute since my last post. The announcement from HHS about “HHS, ONDCP, and HUD Launch First-Ever ‘Treatment First’ Toolkit to Combat Homelessness and Addiction” reminded me that I submitted the op-ed below at the end of June. The newspaper chose not to publish it, so I’m sharing it here. I’ll review the toolkit above next, though I have a feeling that I may reiterate what I’ve already written below.)
The Trump administration believes that mental illnesses and substance use disorders are the root causes of homelessness. Thus, HHS Secretary Kennedy recently announced funding for the Safety Through Recovery, Engagement, and Evidence-based Treatment and Support (STREETS) program. Because of the “unprecedented burden and impact of addiction and mental illness among the homeless population”, he asserted that this funding “aligns with President Trump’s Executive Order on Ending Crime and Disorder on America’s Streets”.
STREETS may help people with mental illnesses and substance use disorders, but it will not end homelessness. People need safe places to call home to recover.
The vast majority of people with mental illnesses and substance use disorders are not homeless. In Washington State, over 2.2 million adults have had any mental illness and over 1.4 million people over the age of 12 have had a substance use disorder in the past year. Compare these numbers with the 163,000 Washingtonians who are homeless. If we (incorrectly) assume that every person became homeless because of a mental illness or substance use disorder, that means over three million Washingtonians will lose their housing. This is wrong. Someone in a Mercer Island mansion drinks bottles of wine between meetings, just as someone in an Auburn apartment takes medication for schizophrenia before going to work.
I work as a psychiatrist in Seattle with people who are currently and formerly homeless. Psychiatric conditions that are common in the general population, like anxiety and depression, are also common among those who are homeless. For many of them, housing is the most effective treatment. Having reliable access to one’s own bathroom and bed reduces stress. A lock on the door assures safety and security.
Practically everyone who is homeless now has had a place to call their own in the past. Because of rising rents, reduced incomes, and the onset of health problems, nearly half of people becoming homeless for the first time are over the age of 50. With older age often comes increased physical and cognitive vulnerability. Anxiety and depression often follow. The loss of health and housing can tip people into major mental illnesses and substance misuse.
In a minority of people, severe mental illnesses and substance use disorders are the primary drivers of their homelessness. Because of their symptoms, they sometimes are unwilling or unable to work with traditional health care systems. Finding these individuals is often the hardest part of my job. I cannot build relationships and then offer treatment if I cannot find my patients. When someone has a stable and safe place to live, it is far more likely we will connect. Only then can people participate in care.
For those who are unable or unwilling to engage in outpatient treatment, civil commitment is the last option. Laws for involuntary hospitalization already exist. Every day, someone is hospitalized against his will. In many instances, this is lifesaving. However, recovery quickly unravels if people have nowhere to go when they are discharged from the hospital. It is hard to attend appointments, take medication consistently, and build a life you want to live when you don’t know where you will sleep.
To be fair, STREETS funding will help the health and wellbeing of some people, including individuals who are homeless. Prevention and early intervention work. Some people at risk of becoming homeless because of mental illnesses and substance use disorders will remain housed. However, psychotherapy and medications are often no match for the stress and chaos that comes with homelessness. Housing is health care.
RFK Jr. has shared his own history with drug use and depression. As far as we know, he never experienced homelessness. Having a stable place to call home was foundational to his recovery. He knew where he could go after attending 12-step meetings; he had a safe place indoors to read books by Carl Jung. Housing alone does not treat mental illnesses and substance use disorders. But treatment alone also doesn’t solve homelessness. People need both.
Maria Yang, MD 