Surely I’m not the only woman who’s done this.
You’re walking down a city street and up ahead you spy a man — it’s almost always a man — raving a chorus of heated gibberish and gesticulating wildly, in private battle with some unseen demon.
You cross the street, avert your gaze and pass quickly, feeling pangs of guilt and sympathy.
Contrary to such concerns, statistics show that people with mental illness are more likely to be victims of violent crime than perpetrators.
But rising incidents of fatalities and serious assaults tied to unhoused people with mental illness, many of them caught up in psychosis, are causing some cities to take drastic action.
Case in point: The mayor of New York recently announced a plan to make it easier to involuntarily commit homeless people who are psychotic to hospitals, where they would be medicated against their will and then — theoretically, at least — handed off to agencies and programs to keep them stable in the long term.
Mayor Eric Adams, who has a law enforcement background, is directing police and first responders to detain such people in a broadening of existing state law, which currently holds that involuntary commitment is reserved only for those deemed imminently dangerous “to self or others.”
He’s expanding that category to include people who simply aren’t caring for themselves, or seem “delusional” about their surroundings or condition.
Adams is reacting to a string of high-profile crimes committed by homeless people in his city, using the plan to forcibly remove those with untreated mental illness from streets and subways. He painted his new policy as a “moral obligation” to help mentally ill homeless individuals, even though they may pose no immediate risk to others.
The fact is, Adams said, many people experiencing homelessness who are in urgent need of mental health treatment often refuse such care.
Other states are adopting similar policies. So, I reached out to San Antonio Mayor Ron Nirenberg to see if such a plan would ever be adopted here.
His short answer: No.
“What we’re seeing is the political pendulum swinging once again on this issue,” toward more reactionary solutions like involuntary commitment, Nirenberg said.
“What we’re focusing on here are more pragmatic, comprehensive solutions, the interventions that have proven to work, like emergency rental assistance, street outreach and affordable housing,” he said.
Nirenberg said severe gaps exist in San Antonio (and elsewhere) when it comes to funding for mental health treatment, something he blamed on state lawmakers, who repeatedly have failed to provide the kind of money that would fully address the needs of unhoused mentally ill people, as well as others who struggle.
“We’re working locally to address those gaps,” he said, alluding to the city’s five year strategic plan, which includes a host of strategies to address homelessness, and the city’s recent success in a federal initiative to rehouse homeless people.
But Judge Oscar Kazen of Probate Court 1, which oversees civil mental health commitments in Bexar County, said the New York plan poses a more nuanced set of issues.
“The problem with mental health care is there is no one answer, unless you’ve got the resources and capacity and laws allowing you to help individuals in such circumstances,” Kazen said. “None of it will work unless you have everything in place.”
One group wants more resources, one wants safety and security, another wants rational laws — but they’re all pieces of a giant puzzle that depend on each other, he said.
The pendulum has actually swung too far in the direction of leaving people to suffer in their own illness, Kazen added. So he’s in favor of swinging the pendulum back some.
“The devil is in the details,” he said. “You need safeguards to guard against abuse, so that you’re not taking in the (homeless) guy who simply chooses to live that way. But why do we have to wait until you’re so bad you’re yelling at dumpsters or getting run over in the street to help you?”
Kazen said he also wonders why San Antonio, the seventh-largest city in the nation, lacks a county psychiatric hospital. The state hospital, which used to take in those deemed a danger to self or others, now reserves beds almost exclusively for inmates who are being treated to become sane enough to stand trial, Kazen said.
“So, what happens now is (a homeless mentally ill person) is taken to a private hospital, where he is unfunded, so the hospital foots the bill,” Kazen said. “He needs 30 days of treatment, after which he should be handed off to housing and other programs to change his life in the long term. Instead, he gets five days and a shot in the arm, and then he’s back out yelling at dumpsters.”
Making it easier to involuntarily commit homeless people who clearly have lost the ability to care for themselves isn’t the only answer, but it may be part of a broader solution, he said.
Monty McCann, who served on the San Antonio Police Department’s downtown bike patrol for 16 years and is now director of Life Safety at Haven for Hope, San Antonio’s comprehensive homeless center, said the New York plan amounts to the old out-of-sight, out-of-mind approach.
“That’s a human nature response — you just don’t want to see the problem,” he said. But making “danger to self or others” calls in the field already put extraordinary pressure on police and other first responders.
“There’s this expectation you have to do something, but what are your resources? There’s not many,” he said. “Then you get into Monday morning quarterbacking, where your actions are scrutinized.”
San Antonio has been more proactive than most cities in addressing homelessness, including unhoused individuals with mental illness. Not just with Haven, a widely acknowledge world-class center, but through such things as specialized training for police and the creation of special, multi-agency response teams that work to deescalate crisis situations and help sick people navigate barriers to care.
Starting in 2017, a collaborative made up of more than 20 groups — the city, the county, major hospital systems and philanthropic organizations — joined forces to see how to better address the needs of vulnerable mentally ill people, including the homeless population.
But to say we’ve got the issue licked is inaccurate by a long shot.
It’s a problem that dates back to the 1960s, when a movement to deinstitutionalize mentally ill people closed psychiatric hospitals across the nation. Such treatment was supposed to be supplanted by community-based health care, which largely hasn’t materialized, or at least not to the extent that it would meet gaping needs.
In San Antonio, the 2022 point-in-time count found 2,995 people were homeless — 1,036 unsheltered versus 1,959 sheltered — which meant the city’s homelessness rate had remained somewhat flat, when compared to the growing population.
But the category that did see a dramatic increase — 77 % — was the chronically homeless, the very group that suffers the most from untreated mental illness.
Adams’ proposal has triggered fierce debate. Advocates and civil rights groups, along with police and EMS workers, have questioned the feasibility and compassion of the new program, saying the system is already overburdened. How will it handle a new influx?
A lawsuit has already been filed, alleging the plan violates homeless people’s constitutional right against improper search and seizure.
Meanwhile, in San Antonio, downtown business owners and others who work and live in the area describe increasing levels of violence among panhandlers and the homeless population, many of whom apparently struggling with untreated mental illness or aggression triggered by dangerous street drugs.
Haven for Hope offers a slew of services, but the reality is many chronically homeless people who are mentally ill simply refuse to go there, out of paranoia, a fear of crowds or whatever other reason.
McCann insists such folks are in the minority — that Haven street outreach teams are often able over time to build trust with even the most delusional individuals and bring them into services and treatment.
Personally, I’m skeptical. I covered homelessness in San Antonio for years as a reporter, and I saw plenty of folks so out of their minds that reaching them would seemed to have required a miracle. Couldn’t enforced medication be part of the answer?
Adams’ approach finds support in unexpected places. Robert Tolle, 41, is a local homeless man with medically treated bipolar disorder who now makes his outdoor camp on the North Side, far from downtown. He said he witnessed a brutal knife attack last summer at a bus stop outside of Haven for Hope.
“Things are definitely getting more dangerous, and the police and city are just looking the other way,” he said.
Tolle said expanding the ability to forcibly medicate mentally ill homeless people would render the situation safer, but it also contains “shades of gray” — he worries police will use such laws to detain cogent people, such as himself.
David Huete, vice president of transformational services at Haven for Hope, said the remedy is actually quite simple.
“Our clients are happy to take medication, but the biggest barrier is they don’t have the money to pay for it, or they don’t have the months to wait for it,” he said. “You take away those two barriers and a lot of this problem goes away.”
Nirenberg points to another, more overarching solution: Permanent supportive housing, a set-up that combines long-term housing with on-site, wrap-around support for residents, such as addiction and mental health services.
In May 2022, San Antonio voters overwhelmingly approved the $150 million city housing bond that reserves $25 million for such projects.
That’s a move in the right direction.
But to truly free our city streets of the specter of unhoused people fighting frightening inner battles would require more millions, if not billions of dollars — and the political will to spend it on society’s most vulnerable.