Homelessness, Grave Disability, and Mental Health Legislation

  • Journal of the American Academy of Psychiatry and the Law Online
  • March 2026,
  • 54
  • (1)
  • 12-20;
  • DOI: https://doi.org/10.29158/JAAPL.250092-25

Homelessness is on the rise in the United States.1 Despite the expenditure of significant human and financial resources, this problem has remained persistent.2,3 Multiple government policies have been unsuccessful, and concerns continue to rise among the public.3,4 In this context, likely because of the immediate effect on urban appearance and the potential to improve public opinion, many governments employ legal measures, including civil commitment, to address homelessness. At times, these authorities revise mental health legislation to make civil commitment applicable to homelessness, but these measures only provide temporary relief while they worsen the underlying problems.5

The latest report from the Department of Housing and Urban Development (HUD) released in December 2024 indicates that 771,480 people are homeless in the United States.1 Thirty-five percent of these people experience unsheltered homelessness, meaning they live in public spaces not intended for human habitation and they do not have access to emergency shelters, transitional housing, or other temporary accommodations.1,6 Families, children, and older adults are experiencing higher rates of homelessness.1,6 Ethnic minority groups are overrepresented among the homeless, and the number of people experiencing homelessness for the first time has increased (Ref. 1, p 5). Homelessness is most prevalent in the urban coastal areas of California and New York (Ref. 1, p 8). Factors contributing to persisting homelessness include a national shortage of affordable housing, financial pressures driven by rising inflation, economic inequality, stagnating wages, high rent, and insufficient temporary housing options (Ref. 1, p 5). Many factors contribute to the current numbers of homeless people, including the surge of migrants and asylum seekers in New York, natural disasters like the Maui wildfires in Hawaii, and the end of COVID-era protections for housing (Ref. 1, p 14).

Those experiencing homelessness have a higher incidence and severity of illnesses and injury.7 Chronic medical illnesses and communicable diseases like hepatitis C are more common among people who are homeless.7 Their life expectancy is 30 years shorter than the U.S. average, with estimated annual deaths ranging from 17,500 to 46,500.8 Mental illnesses, including serious mental illnesses (SMI), personality disorders, and substance use disorders, are more common among the homeless than the general population.1,9,10 In the December 2024 HUD report, approximately 20 percent of the homeless population had SMIs, whereas approximately 15 percent had chronic substance use disorders.11 Homelessness has an intriguing relationship with mental illness. Individuals with mental illness are more likely to be homeless and experience homelessness for longer periods of time.12,13 Then, the experience of homelessness makes people vulnerable to mental illness.13 Homelessness precipitates biological risk factors for mental illness. It also predisposes to, and perpetuates, psychosocial risk factors for mental illness.3,13 Overall, there is a reciprocal relationship between mental illness and homelessness.3

For society, homelessness is expensive. Studies have shown that housing the unhoused costs significantly less than incarceration or the consumption of public services like emergency rooms and law enforcement time.5,14,15 The esthetics of homelessness bother society more. Homeless encampments lead to withdrawal of citizens from affected communities, probable reduction in property prices, increased crime rates, and reduced public safety.16 As with mental illness, the relationship between crime and homelessness is complicated. Crime leads to homelessness, as previously incarcerated people are more likely to be homeless, probably because of barriers to reentry into society.17 In some cases, criminal behavior follows homelessness.13 In addition, even though homeless people are more likely to be victims of crime,18 they also quickly become criminalized, as they are more likely to be charged with status offenses like loitering, trespassing, vagrancy, and sleeping in public spaces, among others.19 Civil commitment can be seen as an alternative to criminalization and perhaps a quicker route to keep the unhoused off the streets.5

Civil commitment laws and policies in the United States have evolved over the years based on public opinion and awareness, developments in psychiatry, and economic changes.20 Since the enactment of the Lanterman-Petris-Short Act (LPSA) in California in 1967, the pendulum of policy action has swung between two poles. One is a response to dangerousness, authorized by the state’s police power, and is aimed at ensuring public safety. The other response focuses on the need for treatment of individuals considered gravely disabled and has its origin in the doctrine of parens patriae, aimed at providing care for those who cannot care for themselves. Of the two poles, the gravely disabled end is more malleable. Hence, whenever there are changes in the factors that drive policies, requirements for committing those who are gravely disabled often get redefined to broaden or tighten the criteria for commitment. When civil commitment is used as a tool to address homelessness, the gravely disabled arm is often broadened.

Grave Disability

Prior to the LPSA, dangerousness to self and others was the criterion for commitment in most jurisdictions.20,–,22 The passage of the LPSA was a milestone in mental health legislation in the United States.21,–,23 A landmark achievement of the act was the codification of the care for those who are gravely disabled, which was defined as being unable to provide for one’s basic needs, including food, shelter, and clothing.23,24 After California passed the LPSA, other states rapidly adopted the gravely disabled arm of civil commitment.20 By 2016, 19 states had provisions for emergency holds for persons who are gravely disabled or unable to meet their basic needs.25 According to the Treatment Advocacy Center, in 2020, only five jurisdictions (Alabama, Delaware, the District of Columbia, Maryland, and New York) had no stipulations for civil commitment for those who are unable to meet their basic needs because of mental illness.26

There have been multiple unsuccessful challenges to the vagueness and constitutionality of the gravely disabled prong.27,–,29 In these rulings, the courts have highlighted the relationship between dangerousness and grave disability. For example, in the California case, Doe v. Gallinot,27 the district court linked grave disability to dangerousness by stating that the gravely disabled prong implicitly requires a finding of harm to self. The Washington Supreme Court in In Re LaBelle emphasized that, under the gravely disabled standard, “the danger of harm usually arises from passive behavior,” not overt acts as in the dangerousness standard (Ref. 28, p 204). The court opined that the standard is constitutional if there is evidence of substantial risk of serious physical harm from failure to provide for essential health and safety needs.28 Even when the courts are not as convinced, they do not outrightly condemn the standard. For example, in Wetherhorn v. Alaska Psychiatric Institute,30 the Alaska Supreme Court, drawing from the O’Connor standard,31 stated that commitment was justified once there is a “level of incapacity that prevents the person in question from being able to live safely outside of a controlled environment” (Ref. 30, p 13).

Although there are valid concerns about erroneous loss of liberty, the continued legal acceptance of the gravely disabled standard provides for an individualized, compassionate, and treatment-focused pathway within the commitment process. This proviso has been helpful in many situations where stakeholders agree that treatment is the goal for the patient.20 Problems arise when the versatility of the standard is used for other purposes, like addressing homelessness. Ironically, one of the major goals of the LPSA was to prevent indeterminate and arbitrary commitment.23 Some have criticized the LPSA and called for a discontinuation of the gravely disabled standard because it has been used to increase questionable commitments.32 Although this conclusion is understandable, the reality is more nuanced. The mental health treatment system needs the gravely disabled standard but with a clearly defined scope.

The LPSA has been further criticized, even by its authors, for its inability to achieve its lofty ideals of community-based care.21,22 After it was passed, the LPSA advanced the deinstitutionalization trend of its time by ensuring the release of many persons with mental illness from California state hospitals. Like other states, many of the discharged patients ended up homeless because of inadequate community-based care and resources following their release.21,22 This connection between homelessness and deinstitutionalization has lingered and has often centered discussions about homelessness on deinstitutionalization and mental illness.33 Even though deinstitutionalization contributed to homelessness, most people experiencing homelessness currently are not persons with mental illness.1,33 Nonetheless, measures to address homelessness are often focused on using a history of mental illness coupled with the gravely disabled standard to commit homeless persons.

In recent times, the gravely disabled standard has been redefined by many governments to make it more permissive. In 2023, California passed SB 43, which redefined the original gravely disabled definition from the LPSA in 1967 to “a condition in which a person, as a result of a severe substance use disorder, or a co-occurring mental health disorder and a severe substance use disorder, is in addition to the basic personal needs…unable to provide for their personal safety or necessary medical care.”34 In May 2025, New York State (NYS) enacted legislation to redefine “likelihood to result in serious harm” to include “a person at substantial risk of physical harm because their mental illness makes them unable or unwilling to provide for their own essential needs such as food, clothing, necessary medical care, personal safety, or shelter due to their mental illness.”35 The effectiveness of these measures to counter either homelessness or serious mental illness remains insufficiently studied; it is important to assess whether they have produced the intended legislative outcomes. As an example, we offer a brief review of the historical relationship between involuntary hospitalization and homelessness in New York.

The New York Experiment

The New York involuntary civil commitment statute of 1964 was based on the narrow standard of dangerousness alone.36 In 1972, it was repealed and amended to include “the possibility of causing serious harm to self and others.”36 In 1982, New York City (NYC) introduced Project HELP (Homeless Emergency Liaison Project) to provide services to homeless New Yorkers.37 In 1987, under this plan, the city expanded the commitment standard to allow involuntary hospitalization of homeless people when they were considered to be in serious danger of harm to themselves within the reasonably foreseeable future.38 These homeless people were to be managed at a designated 28-bed unit in Bellevue Hospital, with plans to scale up to 200 beds in NYC community hospitals the following year.38

Joyce Brown, also known as Billie Boggs, a homeless woman in Manhattan, was hospitalized under this plan in October 1987.39,40 Ms. Brown was usually unkempt and loud. She yelled racial epithets at passersby, panhandled and sometimes burned her earnings, and defecated on the sidewalk, but she was not overtly suicidal or homicidal.39,40 With the help of the New York Civil Liberties Union, Ms. Brown sued NYC and contested “whether the City established by clear and convincing evidence that petitioner Joyce Brown has a mental illness and is a danger to herself or others” (Ref. 41, p 972). The trial court ruled for Ms. Brown, stating that NYC’s evidence was not clear and convincing. The city appealed and the appellate court reversed the trial court’s decision. Ms. Brown appealed but was released from Bellevue before her appeal could be heard.41 In all, she spent 84 days as a psychiatric inpatient.39 Ms. Brown eventually became a celebrity, and her story became a benchmark for the treatment of homeless persons.39 Sam Tsemberis, the former director of Project HELP from 1988 to 1992 later stated, “Over time, what was clear to us is that people kept returning to the street. They were discharged, there was no housing option, and they ended up back usually in the same spot we had met them the first time. We were kind of in this cycle of taking care of acute emergencies, but with no real resolution to the problem.”42

Thirty-five years after the Billie Boggs case, in February 2022, Mayor Eric Adams called for changes in existing laws to address homelessness and mental illness while introducing a new plan to address subway safety.43 The same month, the NYS Office of Mental Health (OMH) released interpretative guidance of existing law to assist clinicians in rightfully determining who should be involuntarily admitted.44 The guidance stated that the combination of provisions in New York Mental Hygiene Laws Articles 9.37, 9.41, 9.45, and 9.58 and current case law “provides the authority to remove and hospitalize people who appear to have mental illness and present a danger to themselves due to substantial self-neglect, with evidence of a recent overt dangerous act not being necessary” (Ref. 44, p 3). Using the connection between grave disability and dangerousness while discounting the importance of being “imminently dangerous,” the document emphasized that “Patients can meet criteria for involuntary admission even when there is no recent dangerous act. Courts have found that evaluating psychiatrists may consider an individual’s whole history when determining if an individual needs involuntary admission” (Ref. 44, p 4).

In November 2022, Mayor Adams emphasized that it is proper to initiate mental health interventions when there is a connection between grave disability and danger to self. He promised that the city will prevent ambiguities surrounding commitment decisions by ensuring that the grave disability standard is clearer in the state law.45 He proposed that discharge decisions by doctors should not only be based on the patient’s functioning at the time of evaluation but should include the patient’s treatment history, recent behavior in the community, and probability of adhering to outpatient treatment. Essentially, the plan would permit more admissions and extend inpatient stays. The mayor then directed that people who are considered to be in mental health crises and may be harmful to themselves should be transported to the hospital.45

There were swift reactions to this plan from diverse quarters. The Bazelon Center released a statement declaring that the plan will disparately affect Black and Brown people and that a focus on community-based services would be a better approach.46 The NYC Bar Association criticized the initiative as unconstitutional under both state and federal laws because the city would carry out involuntary “arrests” using vague criteria that substantially depart from state and federal law.47 Although the Bar Association admitted that the OMH guidance aligns with case law, it criticized broad removal directives that may plunge the city into perpetual legal challenges. It underscored that the plan could potentially increase the stigma against people with mental illness and have disproportionate effects on communities of color.47 The city nevertheless proceeded to implement the plan.

In the annual report of involuntary removals for 2024, the first report after the initiation of the directive, there were 7,060 officer-initiated transports and 758 clinician-initiated transports. Sixty-four percent of the officer-initiated transports occurred in response to 911 calls.48 The report noted that the number of transports is not the same as the number of individuals. Approximately 51 percent of transports were from private dwellings, and only about 10 percent were from public spaces, with another 12 percent from public transportation.48 About 20 percent of officer-initiated transports and about 66 percent of clinician-initiated transports were of individuals experiencing homelessness. Fifty-eight percent of the individuals transported were hospitalized whereas 42 percent were “treated and released.”48 Over half of those transported were Black,48 whereas Blacks constitute only 23 percent of the NYC population.49

As the critics predicted, there is a disproportionate racial distribution among the transported individuals. This difference underlines the need to pay attention to social determinants of health rather than temporary measures. The disparity between the number of transports and number of individuals suggests possible repeat pick-ups, which highlights the makeshift nature of the intervention. It is also disappointing that, for a program designed to target people who are homeless, more than half of the transports were from homes. Nearly half of those transported were “treated and released.” It is unclear what treated and released means. One also wonders if these individuals needed to visit the emergency room in the first place, overburdening the already busy system. For those who were hospitalized, the outcome of their hospitalization is unknown. We do not know if they benefited from acute inpatient care or were connected to long-term services, including housing resources posthospitalization. There are many unanswered questions, but even the available answers fail to demonstrate the effectiveness of this plan. NYC is reenacting policies that were not very successful in the 1980s. Despite this result, in May 2025, New York State expanded the gravely disabled prong and NYC has continued with the involuntary transportation directive.35

Discussion

It is disingenuous to assume that all government initiatives or efforts have the wrong intentions. Project HELP was facilitated with the involvement of mental health professionals.38 The NYS law passed in May 2025 has guidelines to strengthen multiple follow-up programs and allocates $160 million to create 100 new forensic inpatient psychiatric beds in NYC.35 In August 2025, the City of New York announced that services had connected more than 3,500 homeless New Yorkers to permanent housing.50 Additionally, it is important to acknowledge some realities. Homelessness is a complex problem. Making special provisions for individuals who are mentally ill among the homeless is prudent because mental illness is more prevalent in this cohort. Providing care for homeless persons with mental illness, who are often distrustful of interventions, can be challenging.37 Undoubtedly, some individuals will need long-term inpatient and involuntary care for the safety of the individuals and others. Finally, violence, a rare but possible product of untreated mental illness, can be devastating.51

When homeless mentally ill persons are violent, the victims, if they survive, experience lifelong trauma. Families are devastated. The public becomes fear-stricken, and governments tend to hurriedly pass overly restrictive policies. Recent events like the death of Jordan Neely, the homeless mentally ill young man who harassed people on the New York subway52; the trial of Daniel Penny, the former Marine who stopped Mr. Neely by holding him in a fatal chokehold53; and the murder of Iryna Zarutska, a Ukrainian woman, on a commuter train in North Carolina54 have become political and cultural firestorms that may provide fodder for the introduction of harsh but ineffective policies. To prevent the proliferation of specious policies, it is vital to look at the evidence for and against interventions first. Good intentions coupled with old methods that produced superficial results are insufficient. As we clamor for the right policies, it is equally important to brace for the changes that new attempts at combating homelessness might introduce into the practice of psychiatry.

Advocates for the homeless have argued that revanchism and criminalizing homelessness are ineffective solutions17,55,–,57 compared with certain preventive and corrective measures. Preventive measures suggested include increasing housing supply; addressing affordability; intervening with at-risk groups in the foster care system, prisons, and inpatient mental health facilities; providing emergency cash assistance for sudden income loss; and ensuring stability by protecting renters.3,6 Corrective measures include rapid rehousing, permanent supportive housing paired with services for persons with mental illness, and strengthening current housing programs.3,6 The decline in veteran homelessness, the only demographic with reduced homelessness in the latest count, and other successful community initiatives have been cited as evidence that these measures work.1,3,6,57

These proposals are akin to elements of the “Housing First” approach, which has been the policy of the United States Government since 2004.2,58 Those who are critical of the Housing First approach are advocating for accountability, public order, mental health reform, and efficiency.4 This is the current approach taken by NYC, and it is gaining traction nationwide. In July 2025, the White House released an executive order to address homelessness.59 The order noted that “endemic vagrancy, disorderly behavior, sudden confrontations, and violent attacks have made our cities unsafe,” and it proposed that “shifting homeless individuals into long-term institutional settings for humane treatment through the appropriate use of civil commitment will restore public order.”59 The order also stated that the government will institute measures to make it easier to commit and retain those who are gravely disabled, almost mirroring Mayor Adams’ language about prolonging inpatient stays. This raises questions about whether the use of civil commitment measures is appropriate for homelessness.

Expanding civil commitment will not resolve homelessness for many reasons. First, the majority of homeless persons do not have mental illness. Second, there is an ongoing and worsening shortage of psychiatric beds.60,61 Third, emergency rooms, which serve as portals for admission, are already overwhelmed.61 Fourth, hospitalization is not harmless. For marginal cases, involuntary hospitalizations cause destabilization and posthospitalization increases in charges for violent crime, suicide or overdose deaths, homelessness, and unemployment.62 Fifth, the provision of housing vouchers and rental subsidies are comparatively more cost-effective measures.63 Finally, redirecting homeless mentally ill persons to the hospital only furthers the revolving door phenomenon.42 Acute inpatient stays are not the best solutions for nondangerous people with chronic and often treatment-resistant mental illnesses. Wandering the streets or repeated involuntary commitments are not the only options for this group. Evaluating the futility of treatment while considering palliative psychiatry and person-centered community-based support is a worthy suggestion.64 This and other new ideas should be explored for persons who are gravely disabled.

Those who want accountability in managing homelessness also believe that deinstitutionalization has failed.4 Hence, the demands for mental health reform become a prompt to reinstitutionalization, and as the federal government calls for committing homeless persons, the tendency to redefine grave disability, and even dangerousness, will continue. This process will likely lead to legal challenges and changes to current mental health legislation. Landmark cases like Olmstead v. LC,65 which addresses the deinstitutionalization of people with disabilities, may be up for challenge.66 The necessity of dangerousness in O’Connor,31 the least restrictive requirement of Lake v. Cameron,67 and the clear and convincing evidentiary standard of Addington68 may all be contested. The June 2024 Supreme Court opinion in City of Grants Pass v. Johnson69 captures the growing frustration with homelessness aptly and serves as a harbinger of the possible changes to mental health legislation.70

Grants Pass, Oregon is a city of approximately 38,000 people, and about 600 of them are unhoused.69 The city has fewer than 600 shelter beds, necessitating that some of its homeless people sleep on the streets or in parks. Grants Pass’ municipal code prohibited sleeping on public property. This led Johnson et al., who often slept in their cars, to file suit alleging that the anticamping laws violated their Eighth Amendment rights.69 Citing the 2018 Ninth Circuit Court ruling in Martin v. Boise,71 they argued that it is cruel and unusual punishment for cities to enforce criminal restrictions on public camping unless the individual has access to adequate temporary shelter. Both the district court and the Ninth Circuit ruled in favor of Johnson et al. Grants Pass then appealed, challenging the holding in Martin v. Boise.69

In a 6-3 ruling, overturning Martin, the Supreme Court held that enforcing public camping laws against involuntarily homeless people does not violate their Eighth Amendment rights (Ref. 70, p 561), essentially criminalizing involuntary homelessness.69 The opinions in the ruling discussed two landmark cases extensively. The dissent argued that Robinson v. California,72 which concluded that punishment for status violates the Eighth Amendment, should have resolved the case because sleeping in public is part of the status of homeless people (i.e., everyone must sleep). The majority dismissed the ruling in Robinson as an anomaly in Eighth Amendment jurisprudence.69 They opined that camping in public locations is an act and not a status; hence, Robinson was inapplicable. Instead, they cited Powell v. Texas73 and argued that an act can be punished even if it is a product of an involuntary status (Ref. 69, p 548).

Although the Robinson versus Powell debate between treatment and punishment is longstanding,74,–,78 this rejection of Robinson is significant. Robinson champions the ability of the law to be supportive and nonpunitive for involuntary conditions. It is a precursor of many landmark cases, including Rouse v. Cameron,79 Jackson v. Indiana,80 O'Connor v. Donaldson,31 and Addington v. Texas,68 among others. These cases promote the idea that status-based punishment (and interventions without procedural safeguards) violate constitutional rights. For example, in O’Connor, although the Court mentioned that there was no Eighth Amendment violation (Ref. 31, p 588), it ruled that a mere status of mental illness was inadequate to justify confinement.

The current civil commitment framework is largely built on O’Connor, which makes it a potential target as authorities seek to redefine commitment criteria. Infringements upon a person’s liberty based on the person’s status, as evinced in Grants Pass, may be predictive of novel legislation with greater restrictions, which may not be a step in the right direction. Some states are already developing programs and considering legislation that will allow them to involuntarily confine and treat unhoused persons with mental illness, regardless of dangerousness.81 As the dissent in Grants Pass has noted, the idea behind several measures passed by the Grants Pass City Council, such as exiling homeless individuals through one-way bus rides away from town, making a list of unhoused persons available to service agencies, and denying them basic services, were meant for deterrence, not altruism.69 Since the Grants Pass ruling, hundreds of cities across the country have passed bills criminalizing homelessness in a continuation of the accountability trend.82

Another means for this trend to spread is through financial incentives. State and local governments depend on federal dollars through Medicaid, block grants, and Children’s Health Insurance Program (CHIP), among others, to provide mental health services.83,84 These dollars will become even more precious with the passage of the One Big Beautiful Bill.85 The July 2025 executive order outlined measures aimed at “redirecting federal funds toward effective methods of addressing homelessness,” including “to the extent permitted by law, ending support for ‘housing first’ policies that deprioritize accountability and fail to promote treatment, recovery, and self-sufficiency.”59 The current administration’s guidance is clear that it will prioritize funding to jurisdictions that align with the accountability trend. Discretionary allocation of funds would promote alignment with the accountability approach.

Overall, the relationship between homelessness, mental illness, and crime provides an interesting subject for forensic psychiatry. The involvement of mental health legislation furthers that interest. As we anticipate the possible changes to mental health legislation, it is important to note that incessant and unfavorable changes may erode confidence in psychiatry as a discipline,86,87 accelerate the misuse of psychiatry,87 limit our ability to gather meaningful data and conduct impactful research,88,89 and ultimately defeat the purpose of these laws, which is the provision of quality care with dignity while ensuring public safety.86,90

Footnotes

  • Disclosures of financial or other potential conflicts of interest: None.

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Journal of the American Academy of Psychiatry and the Law Online

Vol. 54, Issue 1

1 Mar 2026

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    Homelessness, Grave Disability, and Mental Health Legislation
    • Journal of the American Academy of Psychiatry and the Law Online
    • Mar 2026,
    • 54
    • (1)
    • 12-
    • 20;
    • DOI: 10.29158/JAAPL.250092-25

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    Homelessness, Grave Disability, and Mental Health Legislation
    • Journal of the American Academy of Psychiatry and the Law Online
    • Mar 2026,
    • 54
    • (1)
    • 12-
    • 20;
    • DOI: 10.29158/JAAPL.250092-25

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Keywords

homelessness, grave disability, involuntary commitment