The Day I Ran Over a Homeless Person on My Way to the State Hospital

It was 6:11 am Thursday morning, December 3rd. I was driving to work on a local highway through the predawn darkness, listening to an audiobook.

Suddenly, my car hit something. I almost lost control as the car swerved. There was a loud “BANG!” as my car ran over … a body.

I didn’t know this at the time. Shaken, I drove a couple miles ahead to the state hospital where I work, noticed some damage to the car bumper, and called the Highway Patrol. When the officer came to look at my car, he told me I ran over the body of a homeless person. The officer later shared with me that many cars had driven over the same body that morning as there was a delay between the initial report and the removal.

When he told me what I had done, a feeling of horror and profound sadness flushed through me. Once again, I felt shaken.

What was this woman doing out on the highway? Knowing the homeless population as I do, I wondered if she had put herself in harm’s way as a suicide attempt. Perhaps she was confused or psychotic due to an untreated mental illness or addiction. Or, maybe, it was just an accident.

Homelessness and Adversity

No matter the cause, the incident got me thinking hard about the seemingly intractable problem of the homeless. How can we as mental health clinicians help these individuals, especially in the time of COVID-19, so that tragedies like this don’t happen? If we can land a rover on Mars, why can’t we help those within our reach who have no place to live and who are struggling with mental illness and addiction?

If there were an easy answer, I’m sure homelessness would have been eliminated by now.

Yet, on any given night, over half a million people are homeless. Nearly 34% of them, just under 200,000, live on the streets without adequate shelter. Approximately 7% are unaccompanied children and young adults.1

The main cause of homelessness is lack of affordable housing.2 But this is not the only factor. People living in poverty and those with mental disorders are at much higher risk of homelessness due to a lack of economic, social, and functional reserves needed to cope with adversity. Homelessness disproportionately affects people of color. Some sources suggest that up to 40% of homeless people are Black, even though they make up less than 13% of the US population.2

Trauma and Homelessness Thrive On Each Other, Leading to Trimorbidities

Trauma is almost universal among homeless people – not only does trauma increase the risk of homelessness but homelessness increases the risk of trauma. In one study of homeless individuals, 100% of the women and over 90% of the men reported experiencing at least one traumatic event.3 More than 50% had witnessed someone being badly injured or killed; 50% of the women and 10% of the men had been raped.

Homeless people have 3 to 6 times higher rates of physical illness as well. In one study, 50% of unsheltered people suffered from the trimorbidity of physical health condition, a mental health issue, and a substance use disorder (SUD).4,5

Given the statistics, it is not surprising that the average age of death of homeless persons is about 50 years as compared to 78 years for non-homeless Americans.6 The low life expectancy is often because homeless people die from illnesses that often could have been treated or prevented.

How Can We Reduce Psychiatric Illness Among Homeless Persons?

Supportive housing can work to treat psychiatric disorders in homeless individuals when that housing is paired with social and clinical services. When you give people safe housing and caring support, they will sometimes accept help for their mental health, too – including for addiction and substance use disorders.7

I recently read an article in one of the psychiatry trade journals advocating for the reopening of state hospital beds for those with severe mental illness. Others in the field have suggested this as well8,9 and many, including Vice President Kamala Harris,10-12 are also pushing for the removal of the IMD exclusion which prohibits federal funding (ie, Medicaid coverage) for facilities with more than 16 beds serving those ages 22 to 64 years.13

(See which mental health programs and services Biden’s American Rescue Plan will fund.)

State hospital beds can serve as a type of intensive “supportive housing.” They integrate comprehensive clinical and social services and have the potential to benefit those who are homeless and diagnosed with a psychiatric disorder. Unfortunately, these types of programs require an investment in resources, and perhaps a revisiting of commitment laws that favor allowing severely mentally ill people to refuse treatments they desperately need. It is a difficult ethical dilemma.

How much do we passively allow people to suffer from severe mental illness and addiction – often at a tremendous cost to themselves and to society? If they go to prison, these individuals are often further traumatized. Some of them may end up at a forensic state hospital. But what if we had an ethical and proactive way of intervening before it is too late?

Being Homeless and Mentally Ill: Is There a Path Forward?

Looking ahead, I see two vexing challenges that remain unaddressed by our society – and by our medical community. First, people with severe psychotic disorders such as schizophrenia lack insight into their illness; they likely do not know they have a mental illness, and thus, do not think they need treatment. Second, severe addiction can rob people of sound reasoning and free will, sending them into a spiral of compulsive destruction. Unfortunately, only about 10% of people with addictions seek treatment, in large part because the disease has co-opted their willingness to ask for help.

Letting people who lack the capacity to rationally choose the treatment they desperately need undergo the suffering of homelessness is not a solution either.

Ethically, I might be more prone to prioritize beneficence as a higher value than autonomy, especially when considering how traumatizing and life-threatening homelessness is, and the lack of sound reasoning with psychotic and severe addictive disorders that result in so much harm to this vulnerable population.

How do we help people who desperately need help but refuse help because of the nature of their illness?

To start, we need to support efforts to minimize homelessness and its cross-sectional impact on healthcare, crime, the economy (eg, the costs for incarceration), and overall moral injury.

Advocating with our legislators to develop more enlightened laws and fund the resources needed to reduce homelessness may be a step in the right direction. If you have any resources, ideas, or suggestions on how we, as mental health professionals, can help to address the problem of homelessness in psychiatrically ill patients, I would love to hear from you! Please reach out to Psycom Pro’s Editor to connect.

Related Articles

More on people suffering from homelessness and mental health disorders, including SUDs.

SUD Hospitalization Among HomelessPandemic Policy Changes for People with SUDsDelivering Trauma-Informed Care
References
Last Updated: May 27, 2021