Finding A Home for Mental Health

It was late on a Saturday afternoon in the heart of Chapel Hill, N.C.. The University of North Carolina basketball team had won a big game, and the streets were awash in Tar Heel blue, giddy fans tripping and galloping in all directions. Walking along the street, caught up in the whirl of activity, I turned a corner and saw a young man sitting alone beside a trash bag. He was overdressed for the sunny day, with two coats, heavy pants and combat boots. He huddled over something, clearly concentrating and clearly frustrated. Tentatively, I sat down on the curb and asked, “Do you need help with something?” He slowly turned toward me and extended his arm, then turned his palm upward. In his hand, he clutched a brand new phone— trapped inside its clamshell packaging.  

Over the next hour, I came to learn that this young man (I’ll call him Vincent) was from Arizona, where his mother still lived. Vincent wanted to go home. Earlier, he had asked to use someone’s phone, and they had walked into the Target nearby and purchased him a pre-paid phone. After using my own phone to interpret the complex activation instructions, moving to a free Wi-Fi spot and after several failed attempts, Vincent had a working device. I was elated that I had succeeded in this small task, and we called his mom. After a few minutes, during which Vincent said very little, he handed the phone to me without explanation. Vincent’s mom sounded very far away, very tired, and very sad. She confirmed what I had guessed: Vincent had schizophrenia and often didn’t take his medication. “He wants to come home,” she said, but she didn’t know how that would work. I wondered: Did she mean how would he manage to get on a plane and fly? Or did she mean it wouldn’t “work” to have him return to her care? It didn’t really matter; Vincent had no money and no one to help facilitate that kind of cross-country trip. He was on his own.

Fast forward to 2024. While most people experiencing homelessness in the United States do not have serious mental illness, we still try to estimate the number of people who are experiencing both homelessness and mental illness through different mechanisms. Just how many people are there who fit into this category? The answer, not surprisingly, is difficult to pin down. The National Survey on Drug Use and Health (NSDUH) focuses on the civilian, noninstitutionalized population of the United States. As a result, people experiencing unsheltered homelessness are not typically included in the survey's coverage. From the housing side, the Housing and Urban Development’s (HUD) Annual Homelessness Assessment Report (AHAR) does collect information about the presence of mental illness as part of their annual survey, called the Point in Time Count (PIT).  However, these questions are optional, and HUD allows communities to use different wording and questions to suit local needs and contexts. Abt’s Dr. Meghan Henry, who leads the production of the AHAR, explains, “For a number of reasons, these data are not reliable to capture the full extent of serious mental health issues among people experiencing homelessness. Beyond the variability in how and whether the data are collected in communities, this is personal health information that most people would not share with strangers.”  The PIT question here, in the county where Vincent lives is, “Have you been diagnosed with any of the following conditions?” I imagine that Vincent’s understanding of what that question is even asking would largely depend on whether he was on or off his medication. How he would answer is a different question. 

Counting is critical, since it allows organizations to receive funding to provide services to address the significant needs of this population. But what actually helps? In 2023, Abt reviewed published literature to develop a resource called Expanding Access to and Use of Behavioral Health Services for People Experiencing Homelessness. The guide identifies several approaches, including intensive case management, peer support, motivational interviewing, and the  critically important practice of meeting people like Vincent where they are – both physically and psychologically. In my own community, the Street Outreach, Harm Reduction and Deflection (SOHRAD) program connects people experiencing homelessness with housing and services. The program uses a relationship-based model to provide ongoing engagement and case management for people who are unsheltered. Next door in Durham, Urban Ministries serves three meals a day, seven days a week, 365 days a year, absolutely free. Abt staff support this work through regular breakfast shifts, working alongside peers and other staff.  Programs like SOHRAD and Urban Ministries often find that peers are better able to bridge the gulf between professional knowledge and the lived reality of those on the streets.