The Word “Mental” in Project 2025. (vi + vii)
The sixth instance of the word “mental” is on page 509 in the section about “First-Day and First-Year Administrative Reforms” for The Department of Housing and Urban Development (emphasis mine):
The Office of the Secretary should execute regulatory and subregulatory guidance actions, across HUD programs and applicable to all relevant stakeholders, that would restrict program eligibility when admission would threaten the protection of the life and health of individuals and fail to encourage upward mobility and economic advancement through household self-sufficiency. Where admissible in regulatory action, HUD should implement reforms reducing the implicit anti-marriage bias in housing assistance programs, strengthen work and work-readiness requirements, implement maximum term limits for residents in PBRA and TBRA programs, and end Housing First policies so that the department prioritizes mental health and substance abuse issues before jumping to permanent interventions in homelessness. Notwithstanding administrative reforms, Congress should enact legislation that protects life and eliminates provisions in federal housing and welfare benefits policies that discourage work, marriage, and meaningful paths to upward economic mobility.
The seventh instance of the work “mental” is on page 516 as a footnote to the paragraph above (emphasis again mine):
The U.S. Interagency Council on Homelessness (USICH) was established in the 1990s, and numerous Administrations have devoted enormous resources to the Housing First model, experimenting with various ways to provide federally financed rapid rehousing and permanent housing opportunities. Housing First is a far-left idea premised on the belief that homelessness is primarily circumstantial rather than behavioral. The Housing First answer to homelessness is to give someone a house instead of attempting to understand the underlying causes of homelessness. Federal intervention centered on Housing First has failed to acknowledge that resolving the issue of homelessness is often a matter of resolving mental health and substance abuse challenges. Instead of the permanent supportive housing proffered by Housing First, a conservative Administration should shift to transitional housing with a focus on addressing the underlying issues that cause homelessness in the first place.
Long-time readers will recognize that this falls right into my professional bailiwick…
(cracks knuckles)
… but I won’t spend too much time on the data because there are excellent summaries elsewhere. For example, the Office of Policy Development and Research published Housing First: A Review of the Evidence. There they describe the stance the federal government took in the 1990s, summarized as “treatment first”:
housing was available only to individuals experiencing homelessness who were willing to work for it.
This is exactly what the authors of Project 2025 want. If they know this history, they know that this “treatment first” model did not reduce homelessness, but an alternate model called “housing first” did, and for various populations:
Overwhelming evidence from several rigorous studies indicates that Housing First programs increase housing stability and decrease rates of homelessness. The best available evidence indicates that Housing First programs successfully house families and individuals with intersecting vulnerabilities, such as veterans, individuals experiencing substance use or mental health issues, survivors of domestic violence, and individuals with chronic medical conditions such as HIV/AIDS.
While the authors of Project 2025 argue that “mental health and substance abuse challenges” are the “underlying issues that cause homelessness in the first place”, they again are ignoring data that illuminates the actual underlying issue (emphasis again mine):
Much of the research looks at the variation in homelessness among geographies and finds that housing costs explain far more of the difference in rates of homelessness than variables such as substance use disorder, mental health, weather, the strength of the social safety net, poverty, or economic conditions.
Is it true that there are some people who are homeless because of their “mental health and substance abuse challenges”? Yes. However, their common denominator is not having enough money. There are people with “mental health and substance abuse challenges” who are not homeless and that’s because they have enough money, or someone else has enough money, to pay their rent. (Think of the depressed ladies who buy cases of wine from Costco and return to their suburban homes to drink 20 bottles of wine a week….)
So that’s the data. But, as a psychiatrist who works with people who are or were homeless, let me share some some “n of 1” perspectives about the work.
Importantly, most people who are homeless don’t need the services of a psychiatrist. Could they use mental health support? Sure: When you don’t know where you’re going to sleep tonight, anxiety is a natural reaction. If you find a place to sleep, but there isn’t a door you can lock (or a door, period), you probably won’t sleep well. Without routine access to a bathroom or running water, you can’t keep yourself as clean as you would like, so you start feeling self-conscious about it. It’s hard to perform well at work if you aren’t sleeping well, you don’t feel your best, and you don’t have a place to call home. You know what solves these psychological problems better and faster than a psychiatrist? Housing.
A psychiatrist can help people with significant psychiatric conditions (like schizophrenia) who are homeless. Among the reasons some people have shared with me about why they will not move indoors:
The aliens will assassinate me if I move inside.
I want an apartment, but God tells me that I don’t deserve to be indoors.
If I move in, they will turn on the parametric speakers to make me insane.
Most of these people don’t have jobs because their symptoms get in the way of their ability to show up on time, work with customers, etc. Because many of them have had terrible experiences with the traditional health care system, some are reluctant to talk with me. But, with the essential help of my non-medical colleagues, many will. Some people, with time and relationship-building, will agree to try medication to treat their symptoms. (Yes, this really happens.)
When you don’t have a stable place to live with a door to lock and easy access to cabinets and calendars, it’s hard to take medication as prescribed. Pills get lost. Other people might pilfer them. Someone might run off with your bag. Plus, if medications make you sleepy, you might only take them when you know you can sleep safely. You know what makes it easier to take medication on a regular basis and manage side effects like sedation? Housing.
Maybe you’ve heard about long-acting injectable medications. Instead of having to take a pill every day, you can get a shot once a month. This sounds like an elegant solution, right? Some people are cool with shots, but a lot of people aren’t. (Would you want to get a shot every month instead of taking pills?) But let’s say our hypothetical patient who doesn’t have a place to live is willing to get a shot every month. (This really happens, too, but not as often.) The challenge here is finding the person every month to administer the shot. Maybe they will come to a clinic or other meeting spot, but their symptoms can make tracking time (and appointments) a challenge. I can go out and try to find them, but if they move around (because of their symptoms, privacy, safety, etc.), there is no guarantee that I will. You know what helps people receive their medications like monthly shots on a routine schedule? Housing.
But let’s go to an extreme. Let’s say that I’m working with someone who is homeless whose psychiatric symptoms are severe and dangerous. Maybe they have stopped eating because they are certain that they don’t have internal organs. Or how about this: A man is chasing children with a lead pipe because he believes that the kids are government agents trying to kill him. Here I exercise my coercive power: I go through the steps to hospitalize both people against their wills for psychiatric reasons.
So now they’re not on the streets, they are in a hospital somewhere. Time passes, treatment works, and they no longer need to be in the hospital. So where are they supposed to go upon discharge? They didn’t have a place to live before the hospitalization. In this Project 2025 universe, they don’t deserve housing because they’re not working, so back out onto the streets they go. And the cycle begins all over again.
Let me also tell you that most people under my care want to work. Because people who are homeless live in the same culture as those of us who have housing, we are all indoctrinated in the idea that there is value in work, and your value as a person involves work. The jobs they often want are often completely reasonable. The person who thinks the aliens will assassinate her? She wants to work as a bookkeeper again. The person who fears the parametric speakers? He’s open to working in the print shop. The person who hears God telling him that he can’t move indoors? He’d like to be a barber. But when you don’t have an address to put on your job application, or you don’t have the money to apply for classes or a business license, how can you make your employment dreams a reality?
If the goal is to reduce the number of people who are homeless, then accept the research data and make housing more affordable for all. If the goal is to reduce the number of psychiatrically ill people who are homeless, then ensure that they have stable places to live so they can meaningfully participate in treatment.
But if the goal is to coerce people, with the threat of homelessness as the cudgel, to live according to the values of the Project 2025 authors, then just be up front about it. Just make sure you follow that line of reasoning to its logical conclusion: Put it in writing that you believe some people deserve to be homeless — and thus deserve to die.