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Homelessness as a mental health crisis

People gather on the sidewalk on D Street near the Las Vegas Rescue Mission on Thursday, Oct. 3, 2019. (Jeff Scheid/The Nevada Independent)

This is the second piece in a series by the author on solving the homeless problem in Nevada. You can read last week’s piece here.

There is an oft-repeated lament about the lack of proper mental health facilities in Nevada. By now it’s accepted as fact – Nevada is not doing what a civilized place needs to do to address the mental health needs of its residents. One study puts us dead last in the nation when it comes to providing necessary services. We have an overwhelming mental health workforce shortage and lack of appropriate facilities. And even with the institutions we’ve come to rely upon in Southern Nevada, there are serious issues – such as no useable water in their facilities for weeks on end. So that’s the bad news.

When we discuss our mental health crisis, we often thrash in the abstract to the exclusion of pragmatic problem-solving that would put more bodies in beds. We often aren’t even getting to a discussion of specialized programming and trackable results. We know there are people in mental health trouble out there, but the conversation too often stops with “we need more mental health services” without nuance or attention to scope and specifics — or even identifiable areas where it is most urgent, including in the population of people who are homeless. All the bad stats seem to overshadow an urgency for more digging into the details on mental health services.  

For instance, we have one of the highest suicide rates in the country and a rising youth suicide crisis — yet our largest mental health provider is the jails. Las Vegas also suffered one of the greatest single-day, mass tragedies of loss and injury to human life at the hands of a madman, and we were and are woefully unequipped to deal with the mental health fallout. I mean, it’s enough to make you go…um, crazy. There seems to be a sort of paralysis on addressing mental health because there’s just so much out there — what can we do, other than what we’ve been doing? (Reminder: we’re 51st in the country). So that’s the even worse news.

Add to this the people who are homeless and the vast unmet mental health needs there. So unmet, in fact, that it is absolutely its own independent crisis. But instead of calling it out as such, it’s dumped onto the heap of “mental health challenges” facing our communities — and that is where it is left. One of the things that needs to occur on the road to diminishing homelessness, especially chronic homelessness, is to declare a mental health emergency amongst this population. Then, we must act swiftly and compassionately to address mental health stability in a comprehensive fashion designed explicitly for those who are homeless.

We must also reject cruel and ineffective “solutions” such as criminalization that are being considered as “incentives” to increase shelter usage. By merely encouraging individuals to go get the help we think we would want, by naively overlooking that some will do ethereal math and decide that being on the streets is a better than acquiescing to the regulation and regiment of shelters and services, by labeling anyone who doesn’t choose to get on the onramp to stability as “resistant,” “unreachable” or “criminal”, we overlook the simple fact that a large segment of people on the streets should be triggering our civil commitment statutes.

That loud snap you’re hearing is my intentional breaking of a tripwire on the way to a conversation that needs to be had. That conversation is not about creating a psychiatric outpost on the edge of town in an old prison to hide away people who are homeless, and it is not about (semantically) “arresting” people in a way that is no better or morally different from misusing the criminal justice system to get them out of sight. It is about using laws already on the books and applying specific criteria to assess the danger that an individual on the streets is in and taking those who meet the criteria into involuntary but compassionate care for 72 hours. In that 72-hour period, the government — in conjunction with mental health practitioners and other service-care providers — should be required to implement a safety plan. If more time is needed, the individual should be afforded (at government expense) legal advocates and full due process before a court of law that is focused not on punishment but on ensuring safety and then restoring liberty using all available tools and means.

This is not an idea that can be widely put into practice now, because, well, did you not read the first three paragraphs of this essay? Nevada sucks at providing mental health services on a large scale. But ultimately, if we see the crisis for what it is, and see a clear (if complex and expensive) remedy, we can create effective programs and facilities.

It begins with a fresh look at NRS 433A and NRS 449. These are the laws regulating civil commitments (both voluntary and involuntary) and the facilities that treat people, respectively. Basically, as it stands now, if it’s deemed that you might be out of control and a danger, the government can take you in, assess what’s up and either release you (if you’re stable and out of crisis) or ask a judge to take a deeper look. Currently, civil commitments are a highly used tool for families to contend with loved ones who are deemed a threat to themselves or others (the standard that triggers a need to intervene). But what happens when a person doesn’t have loved ones around to look out for them? The situation should fall to the state, right? And that’s what this proposal is all about: the same compassionate custody that a caring family member would bring about. 

Now, some good news. Recent changes to Nevada law redefined what it means to be a threat to yourself and made it easier to connect the dots between homelessness and dangerous mental health crisis. The new law (AB 85) says that “a  person shall be deemed  to present a substantial  likelihood of serious harm  to himself or herself or others  if, without care or treatment, the person is at serious risk of… incurring  a serious injury, illness or death resulting from complete neglect of basic  needs for  food,  clothing,  shelter  or personal safety.” The Legislature then created another new law (AB 66) that provides for certifications for “crisis stabilization centers” to provide individuals with more options for thoughtful immediate medical care, connection with services and after-care plans. 

In essence, the new laws say that if you can reasonably infer that someone who, say, has no plan for food or shelter in the near future; may have untreated, but serious health or medical concerns; is a target for predators or exploitation; is at risk of a traffic/pedestrian fatality; and does not have the necessary level of mental wellness to do something meaningful about it, we need to take them into our care because they are in a “mental crisis” and need “crisis stabilization.” Ideally, once the person is taken into compassionate custody, the ball will start rolling to remove the barriers to safer and better autonomous decision-making.  

The public is not yet hearing anything from the state on implementing these laws. Why? I’m not sure, but maybe someone reading this column can find out.

Again, the new laws, once implemented, would merely trigger the ability to hold a person in a safe and nurturing space with appropriate hygiene and sleeping accommodations while trained professionals figure out how to best help. It must be a respectful process, one that is mindful of how things can go wrong if not done right. We need a good, convenient facility to bring the person. Something clean and friendly and solely focused on well-being. Possessions and animals should be maintained in safe environments, ready to return to the owner upon assurance of safety. An assessment must immediately occur in order to diagnose any mental illness. There also needs to be an emergency wound care and medical triage center on site, as well as assistance to check or ensure enrollment in Medicaid (or Medicare) where appropriate. There needs to be staff to enter and upload all the relevant data into our Homeless Management Information System (HMIS). Then, there needs to be an introduction to a case-worker (if the person hasn’t already been connected) who immediately begins to formulate and coordinate a safety plan.

If this cannot be accomplished within the maximum, legal time frame of 72 hours, the team that has worked together to that point needs to provide articulable reasons why. The next step would be for a judge to determine if it is in the individual’s best interest to remain in involuntary care. This would happen at a statutorily provided hearing where the individual has a voice — and an appointed attorney. The court at that point could fashion any number of modest or broader remedies, including the appointment of a temporary guardian to manage the affairs of the person, supervise the process, and report back to the court. In other words, the court would order continued care and the state would maintain an enforceable degree of accountability for the greater good of that person.

I know that’s a lot, and obviously it’s very expensive and fraught with the possibility (but not inevitability) of civil rights abuses and racial disparity. Again, though, I want to reiterate and emphasize that something very like this process is already used by private families for loved ones because it’s the right, best thing to do. It does sometimes also get used for people who are homeless, but with nowhere near the level of compassion or thoughtfulness I’ve outlined here. Under the current conditions, most people (read: law enforcement) who might otherwise move to involuntarily commit a person in order to hold and assess them do not do so because they realize there is no useful net gain. The know that they would simply be creating a lot of paperwork to process a person through a (currently) dysfunctional system.

My point is, it doesn’t need to be dysfunctional. Other communities are already realizing that what I’ve proposed here is a pathway to getting a person in the distress of homelessness onto the fast-track to stability and a return to healthy autonomy. Hawaii, for example, is funding mental health outreach street teams and passing more expansive laws to enable mandatory care for those who need it most.

The Metropolitan Police Department and the City of Las Vegas have started experimenting with street teams in an attempt to reach the individuals who need help most and to convince them to get it. But sometimes the offers of help are ambiguous — and require a leap of faith that a person on the street may not be willing to make. And sometimes there just aren’t enough beds and services, even if the are. This isn’t only a connecting the dots problem. This is systems and no-capacity-to-scale-up problem, too. But if done right, an involuntary commitment option can be a powerful instrument in a symphony of viable options.

We have to try. We have a crisis of homelessness and suffering on our streets. And we have a mental health crisis. Funding sources, facilities, agencies/organizations, technology and training (my thoughts on all that are all coming up later in this series) are needed, as is a mindset that this idea runs parallel to, and not instead of, current efforts to get homeless people into safe, permanent housing. There is a lot of good work being done out there. It is just more patchy than the crisis demands, and jurisdictions seem to responding by going into hyper-bicker mode. There are dedicated mental health professionals who are doing their best to make mental health treatment available. There just aren’t enough of them. We have to get up, put up (the money), staff up and unite in taking hold of those who are on a collision course with despair and destruction and compassionately redirect them.

Dayvid Figler is a private criminal defense attorney based in Las Vegas. He previously served as an associate attorney representing indigent defendants charged with murder for the Clark County Special Public Defender’s office. During his legal tenure, he served a brief appointment as a Las Vegas Municipal Court judge. Figler has been cited as a noted legal expert in many places including the New York Times, National Public Radio, Newsweek, USA Today, Court TV and the Los Angeles Times. His award-winning radio essays have appeared on KNPR as well as on NPR’s All Things Considered program.

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