Analyzing Approaches to Homelessness

We need state legislation that creates a crisis intervention model where trained mental health professionals, rather than police, respond to mental health crises.

“For about nine years, I literally did not know if I was going to be killed that day or not. I was just in a terribly abusive situation and needed to stabilize myself and my children. And so the best opportunity was to go into a homeless shelter for domestic violence victims. It was horrifying.” Jessica*, a 43-year-old woman from Ohio, is one of the 26 million people living in the United States who have experienced homelessness in their lifetime. The U.S Department of Housing and Urban Development estimates that over half a million people are experiencing homelessness.

Jessica is also part of the significant unhoused population who struggle with mental health issues. She spent years being shuttled in and out of psych wards with no prospect of permanent housing, turning to hiding behind dumpsters for any semblance of shelter. Her story drastically improved when she moved to New York, where she was connected to appropriate resources. She first needed to feel safe to finally start recovering from a debilitating disorder that had caused her to lose touch with reality.

The issue of homelessness is one that the U.S. has been trying to tackle for many years, employing various strategies to treat the mental health issues that plague people experiencing homelessness and provide them with housing, whether temporary or

permanently. Some of the largest cities in the country known for having high rates of homelessness — San Francisco, New York, and Houston — are combating the issue in various ways.

San Francisco’s Street Crisis Response Team

The link between mental health issues and homelessness is one of reciprocal causality: Experiencing homelessness puts people at a greater risk for psychological distress, but worsening mental health can also impair people’s social and occupational roles, contributing to a loss of housing. In addition, a majority of the unhoused population has experienced trauma, with one 2000 study finding that all women and over 90% of men from an unhoused population in Sydney reported experiencing at least one traumatic event in their lives. Again, homelessness itself can be a traumatizing experience: People struggling with homelessness are marginalized, neglected, isolated, and much more vulnerable to violence.

Helping the unhoused population thus requires a trauma-informed approach, one that empowers the person and gives them autonomy, as well as keeping them physically and psychologically safe. Unfortunately, the first (and sometimes only) point of government contact for people experiencing homelessness are police officers. Police are unequipped to handle mental health crises appropriately, let alone in a trauma-informed manner. The consequences of a first response from law enforcement can be fatal: In 2022, 110 people were killed after police responded to reports of someone behaving erratically or having a mental health crisis.

“We need state legislation that creates a crisis intervention model where trained mental health professionals, rather than police, respond to mental health crises,” Beth Haroules writes for the American Civil Liberties Union of New York, where she serves as Director of Disability Justice Litigation. “Professionals who have experience working with individuals with mental and behavioral health issues must set the rules for responding to a mental health crisis.”

Some cities have already begun the shift to employing civilian crisis response teams. San Francisco’s Street Crisis Response Team (SCRT) began in November 2020, designed to help people experiencing mental health and substance abuse crises. It involved three person teams of social workers, paramedics, and a peer specialist with lived experience, offering a truly trauma-informed response in place of a traditional police alternative.

SCRT was based on Eugene, Oregon’s Crisis Assistance Helping out on the Streets (CAHOOTS) program, which has succeeded in closely collaborating with government and community partners to orchestrate person-centered crisis interventions. In contrast to CAHOOTS, SCRT is a relatively new program, but the results so far are promising.

“The Street Crisis Response Team has proven that we can respond to calls of people in crisis with compassion and clinical skills without having to rely on emergency rooms, ambulances, and law enforcement,” San Francisco Mayor London N. Breed said on the one-year-anniversary of SCRT’s launch. “This anniversary is an important step forward and proves to cities and counties across the country seeking to replicate our model that it works.”

New York City’s Involuntary Commitment Policy

Other cities have doubled down on more aggressive approaches to issues of mental health and homelessness. In late November of last year, New York City mayor Eric Adams announced a new strategy targeting unhoused populations, transferring them from streets to hospitals through involuntary hospitalization, even if they do not pose a danger to others.

However, several mental health and homelessness advocates have pushed back against the new policy. Many have cited a lack of effectiveness: according to a 2001 study from the RAND corporation, empirical evidence on the effectiveness of involuntary outpatient treatment was slim. Others take issue with the idea that involuntary hospitalization can be trauma-informed in any capacity, even if city officials said training would be provided to police officers on “ensuring compassionate care.”

Even if short-term hospitalization could be a short-term solution to stabilizing people suffering from mental health crises, it does nothing to address the social, psychological and physical factors that cause so many to experience homelessness.

“The actual process of being admitted to a hospital and staying in a psych unit can be really traumatic for patients, especially if it’s involuntary,” reporter Caroline Lewis stated in an episode of NPR. “Patients are waiting in this chaotic emergency room environment. If they’re admitted, they have their clothes, phones and belongings taken away. Sometimes patients are subdued using sedatives or physical restraints if they start to get agitated about something. And in general, the whole ordeal can have very mixed results.”

Some, like Lewis, are concerned that there also simply are not enough resources in hospitals to help the unhoused populations that will inevitably be directed there. The president of the Greater New York Hospital Association privately expressed concerns about reopening the 850 psychiatric beds across New York that remain closed, stating that it would be “very difficult” to find the required staff.

Even if short-term hospitalization is a short-term solution to stabilizing people suffering from mental health crises, it does nothing to address the social, psychological and physical factors that cause so many to experience homelessness.

Houston’s Housing First Initiative

In 1992, psychiatrist Dr. Sam Tsembris founded Pathways to Housing, a nonprofit built on the principle that housing is a universal right. Tsembris and his team developed a program which provided rapid access to a settled home in the community along with person-centered supports catered towards individuals struggling with mental health and addiction. The model became known as “Housing First,” a strategy for combating homelessness which has received support from advocates and researchers across the country.

Housing First is not a new policy by any means; the policy has received bipartisan support for nearly thirty years. However, Housing First has increasingly received Republican backlash in recent years. The Cicero Institute, a conservative think tank, has been instrumental in spearheading new anti-Housing First legislation that focuses on the criminalization of homelessness. Missouri recently passed legislation based on a template bill by Cicero which will fine people experiencing homelessness for sleeping on state land.

There is solid evidence supporting Housing First. Four randomized controlled trials found that Housing First resulted in large improvements in housing stability. Housing First has also led to better treatment outcomes, improved quality of life, and reduced healthcare costs. The policy has received support from the U.S Department of Housing and Urban Development and the U.S Department of Veterans Affairs.

Houston has been touted as a model for implementation of Housing First. The Coalition for the Homeless in Houston reports that overall homelessness has decreased by 63% since 2011, and since 2012, more than 25,000 people have been placed into permanent supportive housing.

Housing First has been shown to lead to better treatment outcomes, improved quality of life, and reduced healthcare 

“Before I leave office, I want Houston to be the first big city to end chronic homelessness,” Mayor Sylvester Turner told The New York Times, who recently approved $100 million in funds to cut homelessness in half by 2025.

Although Houston has employed this evidence-based practice and saw notable reduction in their unhoused population, critics of Housing First have remained skeptical about the validity of Houston’s success. One criticism utilized in Cicero’s anti-Housing First arguments is that people struggling with mental health or substance abuse issues would not accept assistance without mandating it as a prerequisite for receiving housing, making some question the long-term sustainability of Houston’s Housing First initiative.

“Houston deserves credit for the progress made in reducing homelessness. But its approach— along with the federal government’s— is likely hitting its human limits, due to its single, merely materialistic focus that too often leads to a life of misery and early death,” one conservative commentator wrote for The Hill.

But, according to the National Low Income Housing Coalition, studies show that Housing First programs are equally, if not more, effective than non-Housing First programs in reducing usage of alcohol, stimulants and opiates. A common misconception may be that Housing First is merely providing housing, but in reality, it also involves case management and the connection of people with supportive services that increase quality of life and housing stability.

The effectiveness of San Francisco’s SCRT program and Houston’s Housing First policy reflects the importance of treating unhoused people with compassion and connecting them with professionals without stripping them of agency. It is unreasonable to expect people experiencing homelessness to undergo the arduous, time-consuming and non-linear process of recovery when their focus is directed towards the most basic tenets of survival. Criminalization and institutionalization is not the answer—providing safety, trauma-informed care, and consistent access to support from the outset is paramount to empowering people experiencing homelessness and helping them secure the longterm stability they deserve.

*Last name protected for confidentiality.

Disha Chatterjee ‘25 studies in the College of Arts & Sciences. She can be reached at c.disha@wustl.edu.