Some homeless people won’t go to shelters. Should they be left outside?

A police officer speaks to an unhoused man with a truck in the background.
Police officer Michael Bennis speaks to a man at a homeless camp that was being cleared by city workers in May 2023 in Portland, Maine. Many of the people who had been living there moved to a new encampment on the Fore River Parkway Trail. | AP Photo/Robert F. Bukaty

If a city can’t provide desirable housing, some advocates urge leaving people in tent encampments alone.

PORTLAND, Maine — All summer, the tent city grew.

Along a popular walking path, the Fore River Parkway Trail, more than 60 houseless people had pitched tents. They brought with them piles of wood, drugs, abandoned furniture, bikes, and shopping carts. They were a visible sign of a growing crisis: The number of people experiencing homelessness in Maine has more than tripled since 2020, and the arrival of more than 1,500 asylum seekers in 2023 alone had put unprecedented strain on Portland’s shelter system. Over 240 tents were spread across the city, but the Fore River Parkway encampment was the biggest.

On a Thursday morning in mid-August, 13 community leaders gathered to decide what to do next. The city’s plan was to clear the encampment on September 6, cleaning the grounds and forcing anyone left to leave permanently. Before clearing began, the group that organized the meeting — the Encampment Crisis Response Team — was supposed to work closely with residents, using “empathy, innovation, and a coordinated approach.” All summer, nonprofit workers had delivered daily meals and tried engaging residents on finding housing.

But it was no secret that their efforts would likely fail and that most of the more than 50 people who remained in the encampment would not move into housing or shelter by the September 6 deadline.

So far, nearly all of the Fore River residents who had been offered shelter spots had turned them down — saying they didn’t like the options or preferred to stay outside. In the weeks leading up to the clearing deadline, few residents living in the Fore River Parkway encampment said they expected they would have to actually leave.

This left Portland with a dilemma, one shared with political leaders in much bigger cities grappling with the growing challenge of homeless encampments: what to do when people staying in tents tell volunteers offering shelter that they’d prefer to stay outside.

As encampments grew in size and number over the last eight years, research into unsheltered homelessness — meaning those sleeping somewhere at night that’s not primarily designed for human residence — has revealed why some people might prefer tents to shelters. Some people experiencing homelessness have had traumatic past experiences at shelters, or object to requirements in many shelters to relinquish their pets and personal belongings. Others do not want to be separated from a partner at a gender-segregated facility or to comply with strict curfews and rules around substance use. I heard several of these reasons from people staying at the Fore River encampment.

Studies estimate that roughly one-third of people experiencing homelessness in the US have problems with drugs or alcohol. Complicating matters is the fact that between one-quarter and one-third of those experiencing homelessness in the US have severe mental illness, with even higher rates for those experiencing unsheltered homelessness.

As public pressure to clear homeless encampments has intensified, a growing number of advocates have argued that if a city is unable to provide an unhoused person with the kind of shelter they need or want (like an apartment or a private hotel room), then the most ethical and compassionate thing to do is to leave them be. “Respect autonomy and self-governance for encampment residents,” advises the National Homelessness Law Center. “Homeless people are the experts of their own condition.”

Some of this positioning comes from a deep concern for civil liberties and a fear of returning to the ghoulish days of mass institutionalization. Some of it is about resource constraints: Most cities don’t actually have available housing to help everyone who might want it, and so advocates sometimes end up defending situations that, while far less than ideal, seem preferable to forcing unhoused people into living situations they don’t want.

In the windowless conference room where the Portland crisis response team had gathered, these debates were playing out. One outreach worker argued that some people were now in shelters because the deadline had provided a sense of urgency. The choice, he said, was either to continue the team’s approach, “or decide that it jives with us morally to support the concept of, like, forever encampments and forever outdoors.” For people like him, he stressed, “that is a far greater sort of moral surrender.”

A few advocates in the room worried that new pink flyers posted up at the encampment the day before, warning that everyone must leave by September 6, would further traumatize the unhoused people living there. Many had moved to the Fore River Parkway trail after they were abruptly forced out from a different Portland encampment back in May.

City officials, meanwhile, were unwilling to acknowledge that an encampment sweep was surely coming or to discuss how it might harm those living there. To talk about the risk of scattering unsheltered people was seen as being unduly negative and insufficiently committed to the original plan.

“I would focus on, you know, the fact that we have 21 days, we have three weeks, let’s try to get as many folks housed as we can and then see where we are,” said Aaron Geyer, the director of Portland’s social services. It was too premature, Geyer told me, to even discuss what a sweep would look like, suggesting — rather improbably — that by September 6, there might be no unhoused people left to clear out.

An unhoused woman looks out from the unzipped window of a tent. Irfan Khan/Los Angeles Times via Getty Images
Monica Quevado watches Los Angeles City sanitation workers clean up an encampment in June 2023. California has gone further than other states in trying to coerce people experiencing homelessness into treatment.

This question of what to do with those who turn down shelter or treatment has gotten entangled with broader, ongoing national debates about involuntary hospitalization, the “housing first” approach to homelessness, and the best way to solve the nation’s drug crisis. For years, people with severe mental illness have been involuntarily committed to hospitals and treatment centers, and more recently, amid rising rates of overdose deaths, leaders have looked to so-called civil commitments for those with substance use disorders, too. Supporters point to research indicating most people with addiction did not think treatment was needed.

Homelessness advocates have been organizing hard against these new civil commitment laws, stressing that only noncoercive treatment and “housing first” — an approach focused on getting people housing and services, rather than requiring them to address health or behavioral issues first — can provide the aid that struggling people need. They are rightly concerned about how new laws mandating treatment could cast a wide, indiscriminate net on those sleeping outside. But other leaders have argued it’s naive at best to suggest that everyone who needs help will ever voluntarily accept it.

Cullen Ryan, who leads the supportive housing nonprofit Community Housing of Maine, said many of his fellow advocates are too quick to back off from encouraging people into accepting help or housing. It’s a dodge, he said, to take people at their word about sleeping outside.

“I hope that wiser minds will prevail, that we as a society will truly care about one another enough to insist that people all deserve to be inside,” he said. “But, you know, to just say, ‘Okay, well, I feel good, because this person’s at least making their own decisions and they want to be outside.’ … I don’t think that’s right. It’s a cop-out, and it’s very easy for all of us to join the cop-out.”

Some lawmakers argue forcing people into treatment is compassionate

Should people be forced to accept housing or treatment if it’s for their own good? The specter of old state psychiatric hospitals looms over the question. Originally meant to provide quality care to people with acute mental illness, these places became known in the 20th century as nightmarish jails not only for those with mental disorders but also for senior citizens, rowdy teenagers, gay men, those with drug or alcohol addiction, and those in poverty.

They were characterized by gruesome forced treatments: lobotomies administered without anesthesia and aggressive electroconvulsive therapies with severe side effects. A political movement to empty out these asylums gathered momentum in the 1970s. Deinstitutionalization was seen as a necessary corrective to decades of cruel state paternalism. The hope was that people with mental illness would be able to get care in their communities. Instead, many people who were released ended up houseless.

Today, as politicians face pressure to act on homelessness and drugs, more elected officials have started to ask if leaders swung the pendulum too far in their turn away from involuntary care. In Oregon, Portland’s Democratic mayor, Ted Wheeler, told a group of business leaders last winter that he wants state laws changed to make it easier to force people into hospitals. “When I see people walking through the elements without appropriate attire, often naked, they are freezing to death … I don’t even know if they know where they are or who they are,” Wheeler said. “They need help and they need compassion.” Republicans in Oregon’s legislature pushed bills to expand criteria for involuntary commitment, though their efforts failed this year.

The state that’s gone arguably the furthest so far is California, where lawmakers have spent several years debating whether to amend a nearly 60-year-old law to expand involuntary psychiatric treatment.

San Francisco City Hall with an unhoused man walking in the foreground. Liu Guanguan/China News Service/VCG via Getty Images
An unhoused man walks by the San Francisco City Hall on August 19, 2023.

The law, the Lanterman-Petris-Short Act of 1967, is regarded as a bill of rights for Californians with mental illness, but it’s been blamed for enabling the abandonment of sick people experiencing homelessness, among other problems. Lawmakers in favor of changing the law say they see it as a moral obligation to make it easier to get individuals into treatment before they die or end up in jail.

One of those lawmakers is state Sen. Scott Wiener, a Democrat from San Francisco, who has pushed bills since 2018 to expand access to state conservatorship — a court-ordered status whereby a family member, friend, or public guardian controls another’s treatment plan. “Clearly we went too far,” Wiener told Vox. “We had these terrible institutions where people who did not need to be institutionalized were, but we went way too far in the opposite direction and I think it was an overcorrection.”

San Francisco Mayor London Breed has also framed forced treatment as the more compassionate course of action, saying of people experiencing homelessness, “Allowing them to deteriorate on our streets when they are incapable of caring for themselves is not humane.”

In 2022, California Gov. Gavin Newsom signed a controversial new law creating “CARE courts” — ostensibly aimed at helping up to 12,000 people with psychotic disorders statewide who are not voluntarily seeking treatment. Individuals could be referred to a CARE court for an evaluation, and if deemed eligible, they could be ordered to a treatment plan for up to two years. Newsom framed the effort as California finally “tak[ing] some damn responsibility for implementing our ideals.”

And now California lawmakers are pushing two more controversial bills to further expand access to conservatorships, including one co-authored by Wiener that would make it easier to subject someone to involuntary treatment if they had a mental health or substance use issue. Wiener insisted his legislation — which is backed by the California State Association of Psychiatrists and the California chapter of the National Alliance on Mental Illness — would be a “very focused and targeted” effort. Supporters point to statistics like the overdose death rate among people experiencing homelessness, which has soared in recent years.

CARE courts and bills to expand conservatorships have been fiercely opposed by civil rights groups, which argue these policies are dangerous distractions from real solutions like permanent affordable housing and may even siphon funds away from voluntary programs. They also worry that forced treatment pushes poor people out of sight, and note that California has long failed to keep track of how many people are subject to such coercive plans.

“Conservatorship is the most extreme deprivation of civil liberties, aside from the death penalty,” said Susan Mizner, the director of the disability rights program for the American Civil Liberties Union, in 2019. Activists also warn that loosening the laws will affect far more people than California lawmakers claim now, widening the path to criminalize or isolate the state’s sick, poor, and disabled.

For now, California officials have largely dismissed these objections, arguing the need to expand other support services is no reason to not move forward with psychiatric care reform, too.

“This is setting the basic ground rules, and changing the standard doesn’t mean everything is going to get immediately implemented in a perfect way overnight,” Wiener told Vox. “Absolutely we need more resources in this area and in mental health. We need more beds, supportive housing, mental health workers, guardians, but step one is let’s at least set up modernized rules that make sense, and then hopefully as soon as possible we can really ramp up the resources.”

The heated debate over whether involuntary treatment “works”

As states move to expand laws for involuntary treatment, the debate about them has grown louder and more urgent.

Opponents of forced treatment argue there’s little empirical evidence to justify the practice and plenty to suggest it can backfire, partly by traumatizing patients and fueling long-term distrust in medical professionals. Many forced rehab programs take place in prisons, and too many addiction programs in America are low-quality, humiliating, and brutal. One review from 2016 found some involuntary treatment programs even increased the likelihood of criminal recidivism.

But the existing evidence is more unsatisfying and murky than some critics of forced treatment acknowledge. Some studies have found involuntary interventions have led to improved outcomes, like being less likely to be hospitalized or staying fewer days in the hospital. The opinions of those forced to seek treatment vary: In surveys, 34 percent to 81 percent of involuntarily hospitalized patients have described their treatment as justified or beneficial. Patients are more likely to perceive forced care as fair and effective if they consider themselves ill, though people with psychotic disorders who report encountering barriers to health care are more likely to see forced care as unfair, even if they think it’s effective.

 Robert Nickelsberg/Getty Images
A man sleeps under a blanket while riding a subway on June 22, 2023, in New York City, where the mayor has pushed to expand involuntary treatment.

Researchers lack clear data on how many involuntary psychiatric holds there are in the United States, though estimates suggest they’re in the hundreds of thousands annually. Experts admit there’s a lot we still don’t know, partly due to poor reporting systems within and across states. There are few randomized controlled trials — often considered the gold standard for social science research, largely due to practical and ethical concerns.

Alex Barnard, a sociologist who has studied the push to expand conservatorships in California, writes, “there’s almost no recent evidence showing the efficacy of longer-term institutionalization or conservatorship.”

Barnard, who ultimately concluded that more people need psychiatric conservatorships in California than are receiving them, told Vox that he thinks opponents are sometimes willing to sacrifice lives in order to defend the principles of voluntary care and the “housing first” approach, which holds that housing should never be conditioned on getting treatment.

“There is a denial and unwillingness to figure out how to help some people who are never going to accept voluntary treatment,” he said. “I support ‘housing first,’ there’s a lot of evidence for it, but we have to figure out how to address the subset of those who just aren’t served by it.”

In New York City, Mayor Eric Adams instituted a new controversial plan last November to hospitalize unhoused people with serious mental illness and urged broader use of a state law that authorizes court-ordered outpatient treatment. Adams argued his plan would tackle a hard social problem that “everyone else punted on.”

Critics of Adams’s new approach said that without significant new spending on psychiatric beds, mental health crisis centers, and permanent supportive housing, vulnerable people will invariably end up back on the streets. Giving police discretion to decide who might be a danger to themselves or others, advocates also warned, was a civil liberties disaster waiting to happen.

Earlier this summer the New York Times reported on the first few people subjected to Adams’s involuntarily care directive, including Mazou Mounkaila, who was handcuffed and transported to a hospital, where he spent the next 104 days treated for schizophrenia. The city’s care contractor, BronxWorks, argued the new forced treatment policy was working, and that most of their clients have since either moved into permanent housing or are on track to do so.

Mounkaila told the Times he liked his new life and even some aspects of his involuntary care. But he had been medicated against his will and says he continues to take antipsychotic drugs so as to not upset BronxWorks staff.

Portland opened shelter beds — but had almost no housing

As Portland’s encampments grew over the summer, complaints from residents and businesses began flooding government lines, Reddit, op-ed pages, and other civic forums. Some argued for a more forceful response, saying it was the status quo that was cruel. Others expressed frustration that unhoused people were turning down shelter beds.

Local advocates describe homelessness in the state as a “perfect storm” — new asylum seekers have arrived as federal pandemic money has run out, remote workers have relocated to Maine, and the affordable housing crisis statewide has worsened. In all but one Maine county, “the average house price is unaffordable to the average income household,” said the state housing authority last year.

A man surrounded by piles of belongings at an encampment. AP Photo/Robert F. Bukaty
A man packs his belongings at a homeless encampment before city workers arrive to clean up the area on May 16, 2023, in Portland, Maine.

An annual census taken in January found 4,258 people statewide, up from 1,297 in 2020. Until recently, Portland, the state’s most populous city, never had large tent encampments, but unsheltered homelessness increased over the last half-decade as rents went up, and as property owners realized they could capitalize on the city’s tourism industry by converting existing apartments into Airbnbs.

Aaron Geyer, the director of Portland’s social services, said city officials wanted to find a “middle ground” between advocates who didn’t necessarily want the encampment cleared at all and the daily complaints they receive from business owners and the public. “Our job, which is never an easy task, is to try to thread the needle and make sure both sides may not be happy but amenable to it,” he told Vox.

Homelessness experts said they don’t want people to draw the wrong conclusions about encampment residents who turned down shelter offers. Though Portland opened a new modernized facility in late March, it’s located in a more remote part of the city, is gender segregated, and bars pets that are not service animals. Other unsheltered individuals are worried about traveling too far away from the substances they’re addicted to. Some people I spoke with cited past bad experiences at shelters.

“When they say they don’t want to go into X shelter or X motel, it’s often because of some prior trauma that has resulted,” said Nichole Fiore, a national researcher on tent encampments with Abt Associates. “If the goal is to close down the encampment and get people indoors, I think we need to be asking, ‘What would it take to get you indoors?’ And really open up that conversation.”

Jessica Grondin, a city spokesperson, cited “health and safety” concerns as the main reason to clear out the encampment, though it was clear to anyone who walked through that there would be fewer sanitation issues if the city had dedicated resources to maintaining it. It was hard to escape the conclusion that the city, by keeping the encampment at a certain level of disorder and disarray, had made it easier to justify clearing.

“They blame things on it being dirty, but then they don’t provide resources to be clean,” said William Higgins Jr., the executive director of the Portland-based Homeless Advocacy for All.

In the weeks leading up to the September 6 clearing deadline, both residents living in the Fore River Parkway encampment and local business owners said they doubted the city would actually make unhoused people leave.

“If 21 of us just go to the courthouse on September 5 and protest, that’s how many people you need to stop something — at least temporarily,” Nate, a man living at the encampment, who’s being referred to by first name only to protect his privacy, told me in mid-August. “Whether that’s an official written rule or not, I don’t know, but that’s the number I heard and that’s what I like and it’s gonna work — guaranteed. Everybody knows it will.”

No mass protests happened, but on September 5, three Portland city councilors issued a statement, asking for a month delay at minimum. Leaders with Preble Street, a local nonprofit focused on homelessness, also asked the city to postpone its clearing.

But early in the morning on September 6, dozens of police officers, nonprofit staff, and city workers arrived for the clearing. Despite the city’s hopeful prediction that the people in the encampment might leave before the deadline, there were more than 65 tents and roughly 50 people still there on clearing day.

Portland’s parks director described the clearing as an “all hands on deck” situation. Kristen Dow, Portland’s director of health and human services, insisted their approach allowed them to employ “best practices.” But she and other city officials all declined to comment on the impact of displacing residents and the harms to people experiencing homelessness that research suggests such sweeps bring.

Over the summer, a total of 180 shelter beds had opened up — but just 18 people from the encampment had ultimately moved to shelter or housing. The residents’ remaining belongings were hauled to a local incinerator. Leaders were not sure where the people who had lived there would go.