Homeless People Need Emergency Medical Care, Not Just Housing

Gonna try to keep this brief and also preface this by saying that my work does not focus on homelessness, however, I do know what we are looking at from a medical standpoint and I know that this vital piece of the picture and that vital context is NOT being reflected in the efforts for justice in this area. Healthcare MUST be addressed in framing of this issue and in how we conceptualize changes to the system. This is less to propose any specific solutions, as this is such a huge and complex problem; but rather, to give people some more information on the medical story here, in hope that this can inform ongoing work. 

A huge portion of homeless people have a Serious Mental Illness (SMI). This includes bipolar one, schizophrenia, schizoaffective disorders, and even major depression. In the US, this is about 30% of the homeless population. In some countries, it is the vast majority. 

A common line or thought process in the social justice movement is essentially, “want to solve the housing crisis? Just give them houses”. Which by the way, I am in total support for. The problem is, is that someone who is psychotic, will not stay in that house. They are going to go wandering around, because they do not have control of their mind, thoughts and actions. Or they will tunnel in it and potentially die there. Housing is not viable when you are dealing with a large population of people with untreated or insufficiently treated psychotic disorders. 

I am bipolar one, and I had a lot of trouble with housing when I was sick — even though money was absolutely not a factor. When you are that sick, you will wander out on the streets, move erratically, end up in temporary housing, you get kicked out of housing; partners, family and friends of psychotic people often outright abandon us, and this is as much of a material factor in the state of homelessness as any other. We need to understand that the physical availability of housing is not the only problem, and that issues of medical care, and community abandonment, are big parts of the picture as well. 

Something that is lost in discussions about homelessness, is the actual medical parameters of the situation. Most people do NOT understand that psychosis is a medical emergency. You can absolutely die in many ways during psychosis. Psychosis actually causes brain damage. The longer and more episodes you have, the more likely you are to have them in the future, BECAUSE of the damage done. How do people propose to help a population of 582,000 people, almost 200,000 of them who are suffering from untreated SMI? 

When we talk about depression and anxiety, we talk a lot about the inner experiences of that person, and how they feel. But when we talk about psychotic disorders, no one gives a shit what the internal experience is like. A lot of people act like we should just let psychotic people run free, as if that is some kind of social progress, to treat us like magical ponies or something, released into the wild; not realizing that you are condemning someone who is experiencing absolute torture and suffering, someone who is at such a state of medical impairment that they are almost totally defenseless, someone who could easily die of suicide, shooting by cops, attacks on them, or drug overdose — condemning them to wander under the pretense of leftist politics. 

This focus on “involuntary” commitment perpetrates the myth that the biggest cause of this is that people with these disorders do not seek or want treatment or would turn it down if offered actually effective treatment. While this is obviously not universal, I am extremely glad that I was “involuntarily” committed and many, many lives are saved through this system each year. Does that mean it’s a good system or a humane system? No. But allowing people to suffer, to agonizingly suffer, is not acceptable, so we need to come up with a better plan.

While a psychotic person might not “look” to you to be in extreme mental anguish, that is because the INVOLUNTARY symptoms of psychosis are causing profound behavioral chaos. You are not in control of your mind and this causes suffering. The extremes of anguish which I cannot even describe. I now look back at my worst episodes of psychosis, and I have pretty serious trauma purely from the level of agony that I experienced in this disease, before we even get to all the bad things that happened to me because of it.

Psychotic people are suffering at a level that is incredibly hard to imagine for people who don’t have these disorders. What we are looking at as far as homeless people with SMI, is a mass-scale medical emergency whose victims are not only suffering inhumane anguish on a minute to minute basis, but often at risk of imminent death. 

Homeless or not, a lot of the care that is provided to people with psychotic disorders — if they can get it — *IS* “involuntary” hospitalization. In fact, bipolar one is typically allowed to progress to the point of needing admission to a psych ward for diagnosis and stabilization. That is a problem with how we treat this: not until it is life or death. Unacceptable.

When I got to the hospital on both of the occasions I was hospitalized, I was totally gone, totally reduced, totally unable to care for myself, unable to understand what was even going on. Psychosis is a medical emergency, and like in many medical emergencies, people are impaired from providing consent for treatment. When someone comes into the ER in and out of consciousness, do you say that they were hospitalized involuntarily when they finally come to? Do you say this of someone who was given emergency surgery to save their lives, even though they were unconscious when they came in? When I was admitted, I was screaming my head off for them to let me go. If they had let me go, you would not be reading this today. I would be dead as fuck. That is what psychosis is: a state of medical emergency that is often fatal. 1 in 5 people with bipolar disorder dies from suicide alone, often from agitated / psychotic depression.

This is like letting 200,000 people bleed out in the streets. 

Anyone who is psychotic, is in a state of medical emergency. It is THAT issue I do not see discussed. While we sometimes talk about a “mental health crisis”, that never reflects the reality that people with psychosis are in a state of active medical emergency, that they need emergency medical care. This takes the measure of the crimes against humanity represented in these issues to a whole new level. 

Once emergency care has been administered, people with these conditions need persisting medical care, and sometimes that medical care can be very complex. Many people are not able to keep up with the significant amount of work that actually goes into managing these illnesses on a day to day basis. It is far more complex than just popping a Prozac. In my case, over the course of being sick with bipolar one, I spent a full month in the psych ward at the hospital. I spent 12 months in an intensive outpatient program. I am in regular therapy, and see a psychiatrist once a month; in the early days, it was far more than that. A psych ward is essentially an ER or ICU, so when you get out, that is the second that you aren’t in imminent danger of dying. Stabilizing actually takes much longer. Getting meds right takes a long time. And all of this is impossible to manage if you are sick, don’t have help, don’t have housing or a care facility, etc. 

So the issue even goes far beyond addressing the actual emergency, as it requires long-term care, and many people with SMI will have symptoms from it that impair their life significantly, and that is also something to account for, which is permanent disability. 

Any efforts to address this MUST include the reality of serious mental illness (SMI), it MUST include the reality of psychosis, and it MUST include a sense of urgency around the medical nature and aspect of this, and a recognition of the extreme suffering that these folks are going through. 

What are the implications of this for conceptualizing housing justice? When I think about how to help, my mind honestly goes straight to large-scale medical operations like we have seen to respond to varied outbreaks, natural disasters, contaminations, and in situations of mass casualty and mass harm in conflict zones. That is the category we are in, in my assessment. That is what I picture for what would make sense here. 

That said, the issues of consent around SMI *are* extremely complex. I am NOT advocating for the existing system whatsoever, and would absolutely love to see better emergency and ongoing healthcare for all of us, and I did find emergency mental health care to be extremely demeaning, inordinately stressful, and traumatizing in an enduring way. This is not about having love for the system, but just the insertion of some more considerations of the problem space. 

More broadly, please have a renewed sense of urgency around us getting medical care AND housing to homeless people. We have hundreds of thousands of people who are out there right now, sick as dogs, dying in the streets of SMI that *is* treatable in the majority of cases. While it sounds quite pithy to say “just give them houses”, the reality is that we are going to need more like a mass-scale medical treatment strategy before maintaining housing is even feasible.