Homelessness is a growing concern in major metropolitan areas across the United States. On her first day in office, Los Angeles Mayor Karen Bass issued an emergency declaration on homelessness, an issue central to her campaign. Strategies to reduce homelessness are desperately needed, but the new directive from the mayor of New York City has considerable consequences for the future delivery of mental health care and the fidelity of the doctor-patient relationship.
emergency room viMental health complaints have steadily increased since the start of the Covid-19 pandemic. In a cross-sectional analysis of approximately 190 million emergency room visits, higher rates of suicide attempts, drug and opioid overdose, intimate partner violence, and child abuse and neglect were observed at the height of the pandemic in 2020. care has outstripped the supply of trained psychiatrists and other providers, resulting in prolonged wait times for care (also known as “boarding”) for patients requiring psychiatric hospitalization. Exacerbating demand through the detention of homeless individuals without expanding other mental health and workforce development services risks further escalating what is already a crisis of continuing need.
Differences in training between police and mental health professionals can increase profile under an involuntary detention policy. Efforts to improve officer education regarding mental health crisis response, including Police Crisis Intervention Training (CIT), are admirable and have demonstrated significant results at the officer level, such as a decrease in stigma regarding to mental health patients in crisis and self-perceived reductions in the use of force. New York City officials have created crisis management training programs for first responders. In emergency departments, however, the formal psychiatric assessment of the need for involuntary psychiatric hospitalization is more robust and requires not only a clinical interview, but also a review of past mental health records and contact with collateral sources that can corroborate the recent level. of a patient’s functioning and any potential decline or lack thereof. The depth of assessment is broader than what police training offers.
Involuntary psychiatric hospitalization is a restriction of rights that should not be taken lightly. As an emergency room psychiatrist who has performed these assessments in large urban academic medical centers for over 15 years, it is often necessary to balance the risk of future debility and suffering from an untreated psychiatric illness (the chance that a patient will commit suicide) with the potential benefit of involuntary hospitalization. Sometimes the calculation is clear and leans heavily towards the benefit of admission. In other cases, the burden of someone’s psychiatric illness – although requiring clinical care – does not reach the legal threshold to justify the withdrawal of the individual’s right to autonomy. Under the New York City plan, some patients deemed to be in need of involuntary psychiatric care may be discharged after a full psychiatric evaluation. This “revolving door” will be taxing for both patients and authorities.
Invoking involuntary psychiatric hospitalization for homeless individuals also weakens the doctor-patient relationship. The cornerstone of psychiatric evaluation is bedside empathy and the therapeutic alliance. I often share with patients that all I know from their experience is what they to choose to share. This choice to reveal and show vulnerability in the crisis rests heavily on trust and agreement, and the New York City plan undermines these essential attributes of good care. The implications are significant, unsubstantiated involuntary psychiatric evaluation discourages involvement with further care when most needed. A 2022 review in the Journal of Nervous and Mental Illnesses found that involuntary detention is associated with decreased adherence to future care plans, as well as a greater sense of patient humiliation and loss of dignity, especially when police intervention and physical restraint are employed. Patients respond much better to partnership than to coercion.
Some may find merit in Mayor Adams’ approach to involuntary hospitalization. Proponents of the policy note that proactively transferring patients in need of psychiatric care to hospitals could lessen the criminalization of people with mental illnesses, preventing further decompensations that might otherwise lead to illegal acts. But this view is short-sighted when considering the long-term influence of such coercion on someone’s willingness to stay in care lengthwise. The chronicity of mental illness requires a long-term partnership with care rather than forced deprivation of autonomy.
Psychiatry as a discipline is founded on the effort to understand and accept others. Empathy is a core tenet of this work, especially in crisis intervention settings such as emergency departments. Any societal policy – however well-intentioned – that violates this basic premise and deprives patients of choice without due consideration of the likely repercussions is likely to be unsuccessful and detrimental to well-being.