Benevolent Cruelty

America’s homelessness problem has been portrayed by much of the media and by many mental-health professionals as a crisis of housing and safe drug usage. Unfortunately, while this view and the policies that follow from it are undoubtedly sincere and well-intended, they are also misguided and will do nothing to address the causes of a problem that has been allowed to get out of hand. In what follows, I want to re-examine the causes of homelessness and the shortcomings of the current approach to addressing it, before suggesting an alternative path forward.

Historical origins

Our story starts with the history of psychiatric care. In psychiatry’s infancy, there was a focus on studying the human mind and curing what was then called “delirium” by any means necessary. Lobotomies, outdated antipsychotic medications, and indiscriminate electro-shock therapy were regularly prescribed and practiced by physicians as a part of their standard quality of care. This did not appear to bother the average citizen at the time—it may be that these practices seemed novel and therefore mysterious/miraculous (particularly if they mitigated psychotic symptoms and behaviors), but public equanimity may also have been a product of ignorance; mental illness was a problem kept out of sight and therefore out of mind.

Whatever the reasons, from roughly 1750 (when patients were referred to as “lunatics”) until about 1960, mental institutions were thought to be the pinnacle of humane care. Things gradually began to change as the civil rights movement gained momentum. Perhaps more importantly, in 1962, Ken Kesey published his novel One Flew Over the Cuckoo’s Nest. Kesey’s story is narrated by a hospital resident and features a variety of other patients and hospital staff. The former are portrayed sympathetically and the hospital staff are depicted as cruel, impressions likely informed by Kesey’s stint working as an orderly in a mental hospital.

Reports of unsanitary conditions and barbaric treatment of patients at these institutions began to emerge which resulted in a series of public scandals. Among the most notorious of these involved the Willowbrook State School for intellectually disabled children on Staten Island. After Senator Robert F. Kennedy toured the facility in 1965, he told the Joint Legislative Committee on Mental Retardation that, “there are many [Willowbrook patients]—far too many—living in filth and dirt, their clothing in rags, in rooms less comfortable and cheerful than the cages in which we put animals in the zoo—without adequate supervision or a bit of affection—condemned to a life without hope.”

The issue struck a personal chord with the Kennedys because John and Robert’s sister, Rosemary, had been lobotomized at the age of 23. After he was elected president in 1960, John F. Kennedy made reforms intended to assist the mentally ill a central endeavor of his administration. This resulted in the passage of two crucial legislative measures: the Maternal and Child Health and Mental Retardation Planning Amendments, which increased funding for research into the prevention of intellectual and developmental disability, and the Community Mental Health Act, which funded community resources for people afflicted by mental illness.

By this point, psychopharmaceuticals had evolved, allowing people to take courses of medication without being confined to a hospital, and concerns were being raised about the economic viability of institutionalization. This led to a movement known as deinstitutionalization, which drew upon the civil rights discourse of the time. Implementation seemed simple enough: mental hospitals would be closed and community resources would be created for people so they wouldn’t have to enter or re-enter an institution. Under the process of deinstitutionalization, patients were returned to their respective families or transitioned to a lower level of care. A new problem, however, emerged—the resources people needed were either not in place or were not growing fast enough to meet the sudden spike in demand.

Another problem was that, culturally speaking, the United States places a great deal of emphasis on individualism and self-reliance, unlike, say, Latin American countries, which are more collectivist in nature. As a president who strongly emphasized individualism, Ronald Reagan further complicated the Kennedy administration’s legacy by making cuts to the department of Housing and Urban Development, dramatically reducing the money available to subsidize supportive accommodation. Several years prior, as governor of California, Reagan had also signed the Lanterman-Petris-Short Act, which further reduced the involuntary hospitalization of the mentally ill.

Families with members suffering from mental health problems suddenly found themselves overwhelmed and unable to provide the rehabilitative care their loved ones needed. Many Americans felt the financial pinch as cultural norms changed. As more women pursued education, graduated with college degrees, and entered the workforce, childcare demands increased. The American family became busier and more productive, but many of those with mental illness consequently found themselves deprived of the care and attention they required. Their autonomy and freedom had increased, but without adequate supervision, they posed a greater risk to themselves and others.

It is easy, in retrospect, to see how this exacerbated the problem of homelessness. Unfortunately, many experts prefer to frame homelessness as nothing more than a housing issue. The problem is that many of the unhoused were housed at one point, but the deterioration of their mental state resulted in behaviors that became intolerable or even dangerous to their families. This is not simply a supply problem—although homes in cities are expensive, they are available.

Further complications

Mental stability increases a person’s success in navigating the perplexities of infinite choice, allowing them to make smarter and wiser decisions. Those with severe and chronic mental illness simply do not have the decision-making ability required to hold down stable, high-income occupational positions, making home ownership unlikely. Drug abuse can aggravate this problem, as many drugs inhibit the functioning of the prefrontal cortex, which is responsible for executive decision-making.

Drugs and alcohol are appealing because they can take the place of relationships, which transient people struggle to form and maintain, and they offer an avenue of escape from the problems of the past and present. Many homeless individuals have experienced childhood abuse, been abandoned by family members, burned bridges in states of psychosis, and/or struggle with other traumas produced by events prior to and during their time on the streets. It should not be surprising that many seek refuge in intoxication that ends up compounding their existing problems.

Many progressive states (for example, California, New York, Oregon, and Washington) have established needle exchange programs in an attempt to mitigate some of the harms caused by drug abuse. Oregon has even decriminalized possession of smaller amounts of hard drugs such as heroin and methamphetamine. Clean needles prevent bacterial infection and help to contain the transmission of diseases like HIV and hepatitis via needle-sharing. In addition, needle exchange programs can offer support and resources to addicts who want to quit and help steer them into treatment programs.

The success of these programs is well documented; they reduce drug-related overdoses, illnesses, and deaths and assist in getting people treatment. The problem, however, is that this harm-reduction approach also creates centralized open drug scenes and markets in cities. While open drug scenes probably aren’t a cause of homelessness, they can attract homeless people and encourage them to congregate there. States in which needle exchange programs are illegal or locally permitted have lower homeless populations. Unsurprisingly, many of these states are purple or red, while states that have legalized such programs are typically blue. The legalization of needle exchange programs across all states would help prevent the problem of homeless migration and concentration around existing sites. But this would require conservative states to adopt a more progressive, harm-reduction-based approach.

Tensions between the public and homeless populations have also risen—citizens and tourists do not want to be accosted with requests for money, witness casual and open intravenous drug use, or be forced to step over bodies, trash, and human feces as they navigate a city. A view is growing that something must be done to reduce degenerative and maladaptive behaviors that have become commonplace in many cities. Homelessness experts claim that this requires a housing-first approach that can move the destitute off the street and provide them with shelter.

A stable living arrangement can certainly help someone to establish a sense of psychological safety, allowing for improved cognitive functioning and better decision-making capabilities. However, simply converting out-of-commission hotels and building subsidized apartment complexes and tiny houses will not resolve homelessness. The problem with simply providing this population with shelter is that they have already shown that they lack the individual responsibility required to live in a dwelling that requires upkeep, communal cooperation, and mental stability. Many (though not all) struggle to trust and cooperate with others, suffer from psychosis caused by mental illness or substance abuse, and do not have the basic living skills needed to thrive independently.

Media portrayals and interviews with experts often portray the homeless population as highly intelligent and functioning but unable to find a stable living arrangement due to unfortunate circumstances. There is undoubtedly some truth to this; however, it is not representative of the vast majority. Providing homeless populations with housing absent psychological and drug/alcohol services is unsustainable. It is premised on the view that housing is a right, regardless of neighborhood, which does not require applied effort to improve one’s mental state. This naturally creates resentment among working citizens who feel they have had to compete and work diligently to afford homes in urban areas. On the other hand, the view that homeless people are morally corrupt deadbeats with no inherent value is callous and dehumanizing and leads to a disregard for effective policy.

Solutions

Solutions to the problem of homelessness will need to involve cooperation between both political parties as well as a state’s residents. Unfortunately, current tribalistic trends have created mutual disgust across the political spectrum. This has encouraged us-versus-them thinking, a zero-sum black-and-white approach to complex and contentious problems, and an upsurge of myside bias. All of this is making bipartisanship increasingly difficult.

Frank Yeomans is a psychiatrist who works with patients with personality disorders. He argues that political tribalism and polarization is partly caused by psychological proclivities—the Left is “depressive” while the Right is “paranoid-schizoid.” People on the Left tend to view themselves as a combination of good and evil which leads to an overly empathetic belief that everyone must be accommodated. On the other hand, the Right tends to believe that people are either good or bad, which leads to a profound sense of mistrust and mischaracterization of those in the latter category.

Both are unhelpfully simplistic ways of understanding a complex world. Viewing homeless people as simply unhoused citizens, on one hand, or criminals and drug addicts on the other, does nothing to serve the population, nor does it help the public. Yes, homeless people are unhoused, and yes, many of them have substance abuse issues as well as untreated mental health disorders. But all of them have a level of autonomy with which they are unprepared to cope. This is what prevents them from engaging in the world with sound decision-making abilities. The only way to help these people is by temporarily removing their sense of autonomy and providing incentives for its return.

Deinstitutionalization was a reaction to the inhumane methods of the psychiatric field in its infancy. A lot has changed since then. The field has reformed many of its practices and improved its ethical standards. In the current environment, reinstitutionalization can effectively satisfy many people’s needs. It satisfies the Left’s desire to house the homeless, providing them with a safe place to sleep, access to hygienic environments and products, and the psychological relief of food on the table. The Right, meanwhile, will surely approve of mandated treatment for psychological and substance-related issues as opposed to the voluntary treatment models currently on offer, and institutions can lower the costs associated with emergency care through preventative services. Finally, people will not be rewarded for maladaptive behaviors with free housing.

However, reinstitutionalization will need several perspectival shifts if it is to be successfully enacted:

1. Reinstitutionalization will need to be rebranded so that it is uncoupled from memories of mental institutions’ grim past. Perhaps redescribing it as adult welfare with an emphasis on short- to long-term mental and substance-abuse-related rehabilitation can help to persuade the public that it is a way to protect the individual as well advance the public good.
2. The public will need to be persuaded that this is the only way forward. In this sense, building and reopening mental institutions is not unlike the resurgence of interest in nuclear power as a means of combatting climate change. While the public fear of a reactor meltdown persists, climate change poses the more significant threat. The current approach to homelessness is doing little to help homeless populations re-enter society or to protect the wider public who want to live in safe neighborhoods. The more money that is poured into solving homelessness through housing-first approaches, the more homeless populations have grown in their respective states.
3. Conservatives and progressives will both have to rethink their absolutist misunderstandings of the causes of homelessness and refocus on how to achieve good outcomes. This will require conservatives to agree to greater investment in services and harm reduction. Progressives will need to place greater emphasis on personal responsibility instead of simply seeing the homeless as victims of circumstances incapable of self-betterment.
4. In order to mandate treatment, self harm will need to be redefined. Ultimately, laws, ethical guidelines for mental health professionals, and organizations such as the ACLU will have to get on board. Someone in the throes of addiction, or an active state of psychosis because they are not taking their medication, should be viewed as a hazard to themselves as well as to others. This will enable a team of medical professionals to prescribe mandatory care designed to nurse a patient back to health and independence.

While there will always be people who live on the streets, some of whom may be perfectly sane, the problem of homelessness does not have to be intractable. Those who would most benefit from institutionalization are the chronically homeless who have lived at least a year on the streets—nearly 27 percent of the homeless population. Chronic homelessness has increased 266 percent in Colorado since 2007. Those who have been unhoused for less than a year, on the other hand, can continue to benefit from community resources (although these need to be expanded so that they are accessible in liberal and conservative states, and rural and urban areas alike).

Moving forward will require bipartisan support, tough love, a reallocation of funding, and ultimately a legal and ethical overhaul if it is to have any hope of success. At this point, the only way to assist the homeless population is by protecting them from themselves. It may not be agreeable to them initially, but once they learn to manage their symptoms and their associated behaviors, they can regain their autonomy. The paradox of abundant choice is what creates a substantial burden for them, and they need to be cared for in an environment where they can gradually earn their freedom by demonstrating to medical and mental health professionals an ability to be competent custodians of themselves, thereby unburdening their fellow community members.

I’ll leave you with this question: Which is worse—giving people absolute freedom if they are a danger to themselves and others or temporarily revoking some of that freedom in order to provide them with services that will help them reintegrate and thrive in their respective environments? To me, the answer is clear. Respecting absolute autonomy enables the problem of homelessness without providing the incentives needed to begin the process of recovery. Benign apathy can result in the most extraordinary acts of cruelty.