Governments Mostly Caused Homelessness and Only Governments can Rectify it – Will They?

By Marvin Ross with Dr David Laing Dawson

Two recent papers outline the cause of homelessness and how it can be improved. The first is a report by Mr Justice Richard D Schneider that has been hidden in the bowels of the Government website since 2015. Schneider developed the Toronto Mental Health Courts. The second is a recent study just published in JAMA Psychiatry on homelessness out of the University of Calgary.

Justice Schneider looked at why we have seen such a huge increase in the mentally ill involved with the criminal justice system and points out how our changing laws have created that problem. The percentage of prisoners with mental illness has more than doubled between 1997 and 2008. Because of a weak Mental Health Act and the lack of sufficient psychiatric beds, those in need of help are either turned away or discharged before they are fully stable.

These unwell people often then end up committing some minor offence and land in the judicial system rather than taken to an ER. Once that happens, matters get worse. Any treatment is via the correctional system then, upon release, there is little treatment or opportunities and people find themselves with little to no employment prospects, they often begin drug taking for escape or self treatment and are lost.

Until 1978 when the Mental Health Act was changed, the act was based on the state holding a parens patriae role as a guardian of the ill. “Mentally disordered individuals are hospitalized if there appears to be a need to treat them and they are not availing themselves of the necessary treatment voluntarily.” This fell out of favour in large part thanks to the civil libertarians and the 1978 Act that replaced this became based on the concept of dangerousness. The state stepped in only if the person was a danger to himself or others. Declining health due to lack of help did not count.

As Justice Schneider said “we may only interfere with an individual’s freedom if he is perceived to be a danger to himself or others. If an individual is not seen as dangerous to himself or others he is free to roam the streets ‘madder than a hatter’. This latter model is the most common in North America.” Add to that the reduction on government spending on mental illness care so that there are even fewer treatment programs for people. The money that was saved from bed closures was to be reinvested in community treatment and supportive housing but governments neglected to do that.

The consequence of all this is that we have large portions of the mentally ill receiving little to no treatment or community support, ending up in and out of jail and filling the ranks of the homeless. If they are lucky, the parents do what they can but it is expensive and exhausting.

The recently published study out of Calgary looked at over 48,000 people from 19 countries who were homeless. Half were from Canada or the US. What they found was that 67% of them had a mental illness. Geographically, 77% of the homeless in North America had a mental illness compared to Australia (47%), Asia (59%), and Europe (60%). In fact, since 2010, the situation has been getting worse. Mental illness among the homeless has gone from 48% to 76%.

They suggested that “people with mental health disorders may be at increased risk of experiencing homelessness due to factors like housing affordability, limited access to care, low income, and problems reintegrating after receiving inpatient treatment.”

A 2023 study by the Fraser Institute found that Canada was near the bottom of OECD countries – 23 of 29 for psychiatric care beds per 1000 population, 18^th on psychiatrists, on expenditures, we are 6^th out of 8 countries on percent of GDP spent on mental health care at 7%. France and England were at 15 and 13%. The Canadian Alliance on Mental Illness and Mental Health put out a report card on services across Canada earlier this year and with a few exceptions it was F across the board on all measures. The best achieved by very few provinces was a D.

And so, what are we doing to resolve this horrific problem? Not much unless maybe you count kicking homeless out of parks or passing out syringes and Naloxone kits. No improvements in the law, increase in psychiatric and addiction treatment services, beds and programs. I may have missed it but I see very little advocacy if any from psychiatrists or medical professionals with suggestions for improving the situation. Same goes for our political leaders.

Not so in the US.

The New York City mayor is implementing increased involuntary treatment to try to improve the fate of the homeless mentally ill. Psychiatrists are demanding that more needs to be done. Their position is that after hospital care is essential along with community supports, assertive community treatment, supportive employment and housing first which involves wrap around support. And they say, lack of psychiatric beds is problematic.

California is implementing a Community Assist Recovery and Empowerment Act (CARE). This would provide increased housing, mental health and substance use services, and other essential services to help. They are investing $15.3 billion for homelessness and $11.6 billion for mental health programs to deal with the crisis. Of course, the American Civil Liberties Union (ACLU) and various disability groups are opposed. They believe that people should live in squalor and their delusions even if they lack the capacity (because of their illnesses) to realize they are sick.

What Dr David Laing Dawson suggests based on his experience watching the deterioration of the mental health system for the past 40 plus years is this:

Homelessness is a very complex problem with underlying factors of economics, available affordable housing, inflation, unemployment, education, family, addictions, addiction policies, municipal laws, provincial and state laws, increasingly incapacitating and lethal drug supply, and untreated mental illnesses.

In the meta study referenced above, it was estimated that substance use disorder contributed to the homelessness of 47%, and antisocial personality disorder 26%, while major depression accounted for 19%, schizophrenia 7% and bipolar disorder 8%.

Addictions (substance use disorders) and personality disorders are not easily treated. To make any kind of dent in this portion of the homelessness problem will require complicated changes to laws, affordable housing, specific programs developed, specialized support systems, rehabilitative activities, easily accessed medical care, and some form of persuasion…….

But if the above figures are accurate, and about 34% suffer from major depression, schizophrenia and bipolar disorder, this means 34% of homelessness is directly linked to treatable mental illnesses – illnesses we can successfully treat with prescription pharmacology, ensured compliance, combined with basic support and housing. And if the studies and estimates are accurate, that figure may actually be above 50%. And this means 50% of the homeless population are homeless principally because of untreated mental illnesses.

At some point people with these illnesses, usually, if not frequently, spend time in the emergency and psychiatric wards of hospitals. (see the Bryenton story)

So….

By law, mandate, or very strong policy, these hospitals could be ordered to never discharge a patient to the street. A place of residence and organized continuing care must be established before discharge.

Such a policy, strongly worded and monitored, would then force the hospitals to a.) involve families always, b.) liaise closely with social housing systems and social agencies, c.) use community treatment orders, d.) develop teams of professionals to manage the transition from hospital admission to life in the community with continuing treatment.