The New York Times’ recent coverage of Utah’s proposed homeless campus has thrust the debate over the project into the national spotlight. And along with the spotlight has come unfounded assumptions about mental health treatment that do not reflect the legal or medical framework for modern psychiatry.
Regarding the plans for Utah’s new facility to have capacity for court-ordered psychiatric treatment, Jesse Rabinowitz of the National Homelessness Law Center made bizarre comparisons to the Holocaust. Gov. Cox expressed bewilderment at Mr. Rabinowitz’s comments the following day and announced that the project was his “top priority” for the legislative session.
Excessive rhetoric, such as that of Mr. Rabinowitz, is easy to dismiss outright. But these comments, along with the more subdued concerns expressed by Sen. Jen Plumb in the same article, speak to a widespread mischaracterization of mental illness, the treatment modalities necessary to respond to it and the urgency with which such responses are needed.
The truth is that Utah needs to expand psychiatric treatment for the homeless mentally ill to properly address this rapidly growing humanitarian crisis.
Severe mental illness (SMI) is a category of rare brain disorders that are distinct from more prevalent and less acute mental health issues like anxiety and minor depression. Psychosis, which is often associated with schizophrenia and bipolar disorder, is an extremely abnormal mental state during which an individual struggles to control their actions or differentiate between reality and misperceptions and is accompanied by delusions and hallucinations. Unmedicated psychosis elevates an individual’s risk of being a victim of crime, can disrupt their ability to live independently and even increases their risk of serious violence compared to the general population.
Over the last decade, homelessness among Utahns with severe mental illness has gotten catastrophically worse. The number of people with SMI living on the street in Utah has increased by 390%, compared to 45% nationally. Moreover, homeless people with SMI are now twice as likely to live outside rather than in a homeless shelter compared to a decade ago. This again outpaces national statistics. It would be reckless for psychiatric treatment not to be a component of the state’s response to homelessness.
But the treatment of severe mental illness is difficult. Decades of research have shown that psychotic disorders affect an individual’s brain such that it can prevent them from recognizing their own illness. This failure to recognize one’s own disorder prevents them from seeking or accepting treatment or remaining compliant with medication.
For these individuals, the only way to responsibly treat them is to do so involuntarily through a court order, often through hospitalization. Ideally, that individual, once medicated, will stabilize and can then create a psychiatric advance directive with their psychiatrist to clarify what they would agree to in terms of future medication and treatment in case of regression. For many, however, continued court-ordered treatment continues long term, but that care is managed while they are living in the community.
Court-ordered treatment is never at the sole discretion of a physician. Rather, it is a legal process that carefully considers whether the individual’s condition warrants this rare, heavily regulated form of treatment, which is reserved for only the most extreme cases. Such due process is a cornerstone of modern psychiatry.
Antipsychotic medication is crucial to an individual’s success in attaining stable housing and employment as well as resisting drugs or criminal activity, which could further undermine their ability to live independently. When people with SMI no longer use their medication, they do not simply regress; their symptoms and brain damage get much worse with each regression. This can lead to increasingly violent episodes of psychosis, an increased likelihood of suicide and extreme social isolation.
The comments of Mr. Rabinowitz and Sen. Plumb characterize involuntary psychiatric treatment as a violation of an individual’s rights. But a right to what exactly?
In our view, these attitudes, while well-meaning, defend a right to be psychotic, a right to cycle through hospitals and prisons, a right to lose one’s livelihood, and ultimately, a right to die on the street. And they do nothing to defend the rights to recover, to live stably and to thrive.
When presented with these two pathways forward for the most vulnerable Utahns, it is clear which one is the compassionate choice.