Many cities struggle with homeless population

In a May 24 guest editorial, Mr. Pete Dinelli complained that Mayor Tim Keller “is funneling too much money to care for Albuquerque’s homeless population.” He states that state and federal governments should accept some fiscal responsibility instead of leaving the problem solely in the hands of cities. I agree with this. Gov. Gavin Newsom in California, in fact, has decided to follow that very recommendation. But I think it is unrealistic for city governments to shirk their responsibility.

Dinelli ends his piece with the following: “A solution to deal with mentally ill and drug addicted homeless people who refuse city services is the initiation of civil mental health commitments by the state to mandate mental health care or drug addiction counseling in a hospital setting after a court hearing determining a person is a danger to themselves or others. Such an approach would get the mentally ill and drug addicted the health care they desperately need and off the streets.”

New Mexico, like every state, has involuntary treatment laws that are designed to do what Dinelli recommends. I practiced psychiatry in six states and one European country. Every one of those six states has laws allowing involuntary commitment if a person has a mental disorder and is determined to be a danger to himself or others. And yet their large cities, like ours, have homelessness problems.

Beginning in the 1960s, thanks to the development of drugs that treat severe mental disorders, state mental institutions began to empty their beds and close. Today the number of beds available in such institutions is approximately 14% of the number available in the 1950s. People who were previously confined were returned to their homes and the community. The problem, it turned out, was that people had to participate in their treatment and take their medications. Unfortunately, treatment noncompliance resulted in involvement with drugs, which worsened the mental disorder’s symptoms. Jails and prisons became de facto mental institutions. When I practiced in Chicago, the Cook County jail had an internal mental health program with an average daily census of 350 inmates.

In the states where I have practiced I’ve noticed variations in how judges interpret involuntary treatment laws, despite similar language. In one state, judges often assumed that a person who is experiencing auditory hallucinations and paranoid delusions is a danger to himself regardless of whether he is making threats. In another state, mental health professionals had to prove that the patient was not only demonstrating danger, but the danger had to be “imminent.” This sometimes led to discussions like, “He says he’s going to shoot somebody, but does he have access to a gun?” If the answer was no, commitment could be denied.

There have been some discussions among mental health professionals about laws requiring patients to comply with outpatient treatment i.e., “outpatient commitment.” But these would involve patients who are noncompliant with treatment and commit violent acts. This involves only a few people because a small minority of mentally ill people are violent.

There is even talk about re-instituting state-run asylums. Such institutions would have to be carefully monitored and adequately funded to prevent their deteriorating into “snake pits.” Do legislators have the will to do this?

I presume that Dinelli knows that every mayor in this country, and in most advanced countries, worries about these issues every day. So Mayor Keller is hardly alone.

Jeff Mitchell is a retired psychiatrist living in Albuquerque