More on homelessness and violence as a public health problem...

 

This is further analysis of the homelessness and violence issue.  As I look back on the title of the White House Executive Disorder as a guy with an interest in rhetoric – I cannot help to notice those elements.  What does the title “Ending Crime and Disorder on America’s Streets” suggest?  First off – a definitive solution.  In other words, if you follow what is in this order that solves the problem – period.  Secondly, it suggests that there is crime and disorder that is widely agreed upon.  The problem is widespread.  Third and implicitly – that the problem was ignored until this administration came along to solve it.   Fourth as elaborated in the subsequent text – if you magically eliminate the problems of mental illness, substance use, and homelessness – the problem is solved.  Let’s look at the reality versus this rhetoric.

The definitive solution: Per my previous analysis this order conflates “crime and disorder” with homelessness, mental illness, and substance use.  It further conflates homelessness with mental illness and substance use.  None of the other features of homelessness noted by the OECD namely youth, the elderly, families, and immigrant status are mentioned. None of the features noted by the United States Interagency Council on Homelessness namely non-white minority status, homeless workers that cannot afford housing, and the fact that housing first options are effective is mentioned. The only solutions presented are law enforcement and forced mental health and substance use treatment.

Crime and Disorder are widely agreed upon:  Looking at the real crime rates in the top 100 cities by population in the US shows some interesting trends.  Some cities with very low crime rates (like New York City) are often held up as examples of crime being rampant in the US.  Other considerably smaller cities with much higher crime rates are never mentioned.  This selective attention from the news media and politicians illustrates that the rampant crime problem is pretty much what somebody decides to say it is - whether there are facts to back it up or not.  That is especially true because current violent crime rates using the same measure are down by 75% since 1993. Crime in cities is like crime in the homeless populations – it is localized and most people have no contact with it. Apart from occasional mass protests – I am not aware of any consistent widespread disorder in American cities that needs to be addressed.  I don’t think it is too much to consider that hyperbole.

The problem was ignored until this administration came along:  More hyperbole considering the obvious examples of lawlessness exhibited at the highest levels of government by this administration.  The January 6^th Insurrection was not as result of homelessness, mental illness, or substance use.  Neither was the pardon of all of those who were convicted.  The strong message in this executive order is that the homeless, mentally ill, and substance using populations are not above the law and need both the criminal laws and civil commitment laws enforced against them.  That is hypocritical considering the numerous incidents in this administration giving the strong message that certain people with many resources are above the law.  The message that nobody in the US is above the law falls apart under that scrutiny and this administration has no higher moral ground on enforcing the law than any other.  Further – it can be argued that consistent changes since 1993 have resulted in a major drop in violent crime in the US and stating otherwise is not historically accurate.  

The magic elimination of the problems: At this point – I hope that I have illustrated why the title of the executive order is grossly exaggerated.  On that basis alone eliminating the states problems of homelessness, mental illness and substance use would be expected to have no impact.  In the previous post, I also examine why the proposed solutions will not put a dent in a non-system of care that has been rationed for profit by the same politicians charged with improving it.  Massive cuts in health care spending and research by this administration can only make things much worse rather than better.  President Trump seems to think that if he orders something and does not provide resources people with either scramble to provide them for free or law enforcement will solve the problem by mass incarceration.

That is the rhetoric associated with the current executive order, but what is the reality.  Rhetoric flows both ways and for a long-time advocates for the mentally ill took the extreme that there was no violence risk or that it was not any greater than violence from people with no mental illnesses.  As an acute care psychiatrist, one of the commonest reasons people are admitted to acute care units is violent or aggressive behavior. I have assessed and treated thousands of those admissions and know the underlying causes, but have no good data on what it looks like in the community.  As can be imagined that real world data is difficult to come by because it involves access to information in a number of databases and a major effort to synthesize all of it.

That brings me to a recent study that I think was very well done and could probably not be done in the US (1).  The study was registry based and done in Denmark by a group of researchers with expertise in this problem. The study cohort was 1,786,433 Danish residents between the ages of 15-42 living in Denmark at some point during the ten year between January 1, 2001 and December 31, 2021.  The primary outcome was any violent offense leading to conviction as noted in the table below: 

 The authors used data on multiple registries in Denmark including the Danish Civil Registration System, the Central Criminal Register, the Danish Homeless Register, the Psychiatric Central research Register, the National Patient Register, National Register of Drug Abusers, and the National Register on Treatment with Heroin and Methadone.  The substance use registers were available only for a 10-year period and were used as a quality check on the other data.  This methodology is also why this kind of study cannot be done in the US. In the US all this data is siloed with respective insurers, managed care companies, pharmacy benefit managers, and pharmacies.  It is considered proprietary data that is typically out of the reach of most researchers.  The privatization of healthcare in the US has made this kind of research nearly impossible to do.  I consider this to be a conflict of interest because the same healthcare companies that profit from rationing healthcare control all the data needed to assess whether they are doing an adequate job.  

The main aggregation of data is illustrated in the first two tables.  During the study period a total of 55,624 experienced no homelessness and were convicted of their first violent offense or 55,624/1,771,879 = 3.13% of the sample.   1,460/14,555 = 0.08% of the sample experienced homelessness and were convicted of their first violent offense.  Without considering cultural or geographic factors that means if you were walking through Denmark about 3.2% of the non-homeless population over the time course of this study has first time violent offenses.  At the same time, 0.08% of the total population over this same period are violent first-time offenders who have also experienced homelessness (1,460/1,771,879).  In other words, all things being equal you are 38 times more likely to encounter a violent offender who has not been homeless than one who has.  That hardly seems like an argument for ending “crime and disorder” by ending homelessness.   

A Bayesian (based on prior probabilities) or cultural argument could be made that the first violent offense rate in the homeless is three times higher in that population than the general population and therefore caution should be used in homeless encampments. An extreme argument could be made that this is a reason for removing these camps.  But the fact is 90% of those people would not have violent offenses and there are certainly subcultures across any major city where the prevalence of violent crime is as high if not higher.  Is it rational policy to excise those neighborhoods from any city?  The heat map below is a graphic county by county representation of annual average violent crime rates.  The gray areas are unreported.  There are clearly high crime areas in the absence of significant homeless populations.  The heatmap below plots the number of reported offenses per 100,000 of population.  Data is from the FBI’s Uniform Crime Reporting (UCR) Program and violent crime is defined as four offenses: murder and nonnegligent manslaughter, forcible rape, robbery, and aggravated assault. 

The main data analysis in this project involves calculating incidence (defined as cases/10,000) and incidence rate ratios or IRR defined as the incidence in the homeless population/incidence in the non-homeless population.  The example below is from Supplementary Table 7a.  Association of homelessness and specific violent offences leading to conviction in men (10,623,486 person-years), 2001-2021. For the category “homicide and attempted homicide”.   

Raw Data	Incidence	Incidence Rate Ratio (IRR)
Homeless cohort: 36 cases/74,706 person-yrs x 10,000	4.8	4.8/0.4 = 12.2
Non-homeless cohort: 446 cases/11,144092 person-yrs x 10,000	0.4

 Calculating the IRRs across the board, the authors illustrate that the risk in the homeless cohort is generally many times greater for first violent offenses than in the non-homeless cohort. An additional substance use problem increases the IRRs further. Homelessness alone increased the risk of first violent offense by 5-6 times.  The degree of homelessness by the number of repeat contacts with homeless facilities increases the risk higher suggesting there is a duration factor (see supplementary table 4). In looking for explanation they consider that the best defense may be offense (violence perpetration explained as self-protection), adverse childhood experiences, the breakdown of social norms in homeless environments, and using drugs particularly methamphetamine as a coping strategy. 

There are also obvious environmental and ecological factors in homelessness that may be associated with violence.  Relative to any typical living environment there is limited privacy and security.  There are far fewer locked doors, security cameras, and alarm systems. Crowding is a problem that in general is associated with more conflict and violence.  Noise is an additional problem.  Poverty is a complicating factor that can make things worse if there are people getting retirement or disability checks at specified times or who are known to be carrying food or money. 

The neuropsychiatric and psychiatric disability aspects of homelessness were not explored to any degree in this paper.  Many homeless people come to the attention of law enforcement and end up in jail or transported to local emergency departments.  In both settings significant psychiatric disorders are noted and may or may not be treated. Severe psychiatric disorders can lead to many impairments associated with violence including delusional thoughts, impaired insight and judgement, and overt agitation and aggression. All of that behavior is worsened by alcohol and substance use which are also independent risk factors.   

The authors conclude for all the problems noted in their paper that homelessness is a significant public health problem that needs to be addressed.  They have made that assessment in a Scandinavian country with less income disparity and a more robust safety and medical network than the US.  In the US we have no definitive research – only a political statement in the form of an Executive Order that mischaracterizes the problem.  That Order also has clear parallels with previous action by the administration against immigrants because of their purportedly higher crimes rates, rates of mental illnesses, and substance use.  In that case it was shown that native born use citizens have higher rates of violent crimes, property crimes, and drug crimes than either legal immigrants or native born citizens (2).

The Executive Order in question has no scientific, rational, or moral basis.  Further – the party that supports it is long on a states’ rights approach that allows politicians to not provide needed medical and housing assistance to people in their own states.  At a national level – they have severely cut budgets that will result in the closure of hundreds of facilities (hospitals and substance use treatment facilities).  The idea that a public health problem can be addressed by removing resources and adding more law enforcement is pure fantasy - or politics. 

George Dawson, MD, DFAPA

References:

1:  Nilsson SF, Laursen TM, Andersen LH, Nordentoft M, Fazel S. Homelessness, psychiatric disorders, and violence in Denmark: a population-based cohort study. Lancet Public Health. 2024 Jun;9(6):e376-e385. doi: 10.1016/S2468-2667(24)00096-3. PMID: 38821684.

2:  Light MT, He J, Robey JP. Comparing crime rates between undocumented immigrants, legal immigrants, and native-born US citizens in Texas. Proc Natl Acad Sci U S A. 2020 Dec 22;117(51):32340-32347. doi: 10.1073/pnas.2014704117. Epub 2020 Dec 7. PMID: 33288713; PMCID: PMC7768760.

Graphics Credit:

Both graphics at the top of the post are from the Department of Justice Bureau of Justice Statistics dashboard at:  https://ncvs.bjs.ojp.gov/multi-year-trends/crimeType

The heatmap USA graphic was produced by me using the Datawrapper interface and FBI data. 

The Autocratic Approach to Homelessness

 

President Trump issued another poorly thought out Executive Order yesterday entitled ENDING CRIME AND DISORDER ON AMERICA’S STREETS. It contains many myths about homelessness as well as an unrealistic approach.  As a psychiatrist who focused on this issue in the population I treated for decades, I consider myself qualified to comment on this executive order and why it will fail.  Many of the central points have already been covered on this blog and I will connect to them when relevant.  Here is a section by section look.

“The overwhelming majority of these individuals are addicted to drugs, have a mental health condition, or both.  Nearly two-thirds of homeless individuals report having regularly used hard drugs like methamphetamines, cocaine, or opioids in their lifetimes”

There is the common conflation with homelessness and drug addiction and mental illness.  While these conditions are overrepresented in homeless populations – the idea that the overwhelming majority of the homeless are drug addicted or mentally ill is a myth per the government agency that directly monitors the problem (3). According to that agency the majority of the homeless do not have mental health or substance use problems and the majority of people with those problems are not homeless.

Further violent crime rates are about ¼ of what they were in 1993.  It follows if homelessness is higher in the context of dropping violent crime rates it is not likely a causative factor.

The order conflates mental illness with violent crime and suggests that it puts the public at risk for violent crime.  It suggests that the solution is to get them off the street and into institutions to protect the public.  Based on the lack of connection to crime that is a doubtful solution.  Further there has been a decades long initiative by federal and state governments to shut down long term bed capacity.  The US currently ranks 30 of 35 OECD countries in terms of psychiatric bed capacity.  That current minimalist bed capacity does not meet suggested standards to keep emergency department waits at an acceptable range and there is no evidence that the trend is changing.

The United States already uses jails as the largest psychiatric institutions.  Roughly 70,000 of the 350,000 incarcerated have a significant mental illness and receive various levels of inadequate care.  So where exactly are the “long-term institutional settings for humane treatment” supposed to come from? 

“seek, in appropriate cases, the reversal of Federal or State judicial precedents and the termination of consent decrees that impede the United States’ policy of encouraging civil commitment of individuals with mental illness who pose risks to themselves or the public or are living on the streets and cannot care for themselves in appropriate facilities for appropriate periods of time.”

I have written about civil commitment may times on this blog.  I have personally initiated and testified in hundreds if not thousands of civil commitment, guardianship, and conservatorship proceedings over a period of 35 years in the states of Wisconsin and Minnesota.  As far as I know there is no US policy to encourage commitment.  All civil commitment comes down to a county decision by a judge in that county.  Further – that commitment decision is affected by real world circumstances on the ground at the time including the financial state of the county, the number of commitments done per year, the ideological biases of the attorneys and judges, and the known outcomes of the court proceedings.  As an example of the latter, if a judge releases a patient from a hospital without commitment and that person kills or injures someone or themselves – it is less likely that court will take a similar risk in the future.

Inability to care for self is the third standard for commitment after danger to self (aggression directed at self as self-injurious behavior or suicidal behavior) and danger to others (outward directed violence and aggression).  It is the least likely standard to result in civil commitment and the most likely to result in a patient being discharged back into a homeless situation.

On a social media forum, a link was posted to me about 18 U.S. Code § 4248 Civil commitment of a sexually dangerous person. Although it was not explained it seemed to be a rebuttal to my statement that all commitments are local.  Sexually dangerous person is not a psychiatric diagnosis and it is not likely to be a significant factor in homelessness.  Additionally, the federal government does not track this diagnosis in terms of the total number of people incarcerated because of it. 

“provide assistance to State and local governments, through technical guidance, grants, or other legally available means, for the identification, adoption, and implementation of maximally flexible civil commitment, institutional treatment, and “step-down” treatment standards that allow for the appropriate commitment and treatment of individuals with mental illness who pose a danger to others or are living on the streets and cannot care for themselves.”    

This is an ironic statement considering the massive cuts to Medicaid and long history of federal cuts to any programs that fund long term care of the mentally ill.  Medicaid is a major funder of both health care for homeless populations and people with serious and persistent mental illness.  The idea that there will be funds available to massively convert the current rationed, stripped down services to a cornucopia of outpatient, inpatient, and residential services is more than a little unrealistic. 

A realistic goal would be to fund Assertive Community Treatment (ACT) and Forensic Assertive Community Treatment (FACT) teams across every county in the US. This approach to supportive treatment has been known since 1975 – but rarely encountered due to rationing at various levels.  The goal of this treatment is to support people with severe mental illnesses living housed and independently in the community and assisting them every step of the way with access to medical and psychiatric care.  There is no more humane approach. 

“Fighting Vagrancy on America’s Streets.  (a)  The Attorney General, the Secretary of Health and Human Services, the Secretary of Housing and Urban Development, and the Secretary of Transportation shall take immediate steps to assess their discretionary grant programs and determine whether priority for those grants may be given to grantees in States and municipalities that actively meet the below criteria, to the maximum extent permitted by law: (i) enforce prohibitions on open illicit drug use; (ii)  enforce prohibitions on urban camping and loitering; (iii)  enforce prohibitions on urban squatting”

Are there grants for enforcing existing laws?  With the draconian cuts already made by this administration exactly how much is available to enforce existing laws and would it be used with more effect in other areas. Trump has already cut $27 billion in funding for affordable housing and that has been estimated to affect 23 million households.  Homelessness assisted grants have been cut by $532 million or 12%.  These proposals have been described as “devastating” by housing advocates.  That is hardly a serious effort to address homelessness.

Instead, this appears to be an attempt to villainize the homeless and blame them for their predicament.  The wording in this section about monitoring unregistered sex offenders and suggesting that all arrested homeless are screened as sex offenders seems like the approach taken with undocumented immigrants.  Suggest a group of people are guilty until proven innocent and further suggest that law enforcement can make any problem go away.

“..ensure that discretionary grants issued by the Substance Abuse and Mental Health Services Administration for substance use disorder prevention, treatment, and recovery fund evidence-based programs and do not fund programs that fail to achieve adequate outcomes, including so-called “harm reduction” or “safe consumption” efforts that only facilitate illegal drug use and its attendant harm”

This is an overtly dangerous section of the order.  What is the administration calling “harm reduction”, “safe consumption”, and “illegal drug use”.  Would medications for opioid use disorder treatment (MOUD) fall under this category?  Would clinics prescribing methadone maintenance and buprenorphine maintenance be under even tighter scrutiny that they currently are? The wording suggests a level of accountability to an administration that clearly has none itself.     

This executive order is a good if not perfect example of an authoritarian approach to the problem.  Experts in the areas of homelessness, civil commitment, mental illness, and substance use have not been consulted.  Rather than expertise we see and overriding theme that law enforcement will be used to crackdown on the homeless. It suggests that there are systems of care that do not exist and cannot exist due to previous rationing and the more draconian measures from this administration.  In all of the rhetoric about the homeless problem in the US, the average American is led to be believe that this is a crisis unique to this country.  Real data (1) suggests otherwise.  The US has had a roughly 0.2% of the population homeless over the past 13 years and this is comparable to many OECD countries in Europe. Further – this is higher than the social democracies in Scandinavian countries and homelessness does correlate with economic disparity – another factor poorly addressed by this administration.

For all the above reasons – I don’t see any reason why this order will have much of an effect on the homelessness problem.  It probably will present many photo-ops of law enforcement disrupting homeless camps and arresting people.  The unfortunate outcome here is that there is ample opportunity for doing good across many problems – but apparently little interest in that.      

George Dawson, MD, DFAPA

 

References:

1:  OECD - Social Policy Division - Directorate of Employment, Labour and Social Affairs OECD Affordable Housing Database, 2023. – http://oe.cd/ahd

2:  ASAM Statement on Executive Order to Increase the Use of Involuntary Civil Commitment of Unhoused People with SUD.  https://downloads.asam.org/sitefinity-production-blobs/docs/default-source/advocacy/press-releases/asam-statement-exec-order-final_7-25-25.pdf

3:  United States Interagency Council on Homelessness.  Data and Trends.  (accessed 07/25/2025):  https://usich.gov/guidance-reports-data/data-trends