Response on Homelessness, Mental Health, and Substance Use

The recent executive order, Ending Crime and Disorder on America’s Streets, highlights real challenges facing communities: visible homelessness, public safety concerns, and the acute needs of individuals with mental health and substance use disorders. It is undeniable that some people experiencing homelessness struggle with mental illness or substance use, and these issues can be associated with higher risk of victimization, encounters with law enforcement, and challenges in maintaining stable housing.

However, the EO mischaracterizes the problem and proposes solutions that evidence shows are ineffective or harmful. Contrary to the claim that the “overwhelming majority” of people experiencing homelessness have mental health or substance use disorders, research consistently finds that:

• Most people experiencing homelessness are not chronically addicted or mentally ill. According to the National Alliance to End Homelessness, about 25–30% of the homeless population experience serious mental illness or substance use disorders, and fewer have both concurrently (NCH, 2025, 2017)
  
• Homelessness is primarily a housing problem, not a mental health problem. Access to affordable, stable housing is the strongest predictor of ending homelessness (Colburn et al., 2022)
• Evidence-based “harm reduction” programs—such as overdose prevention, safe injection sites, and syringe exchange—reduce morbidity and mortality, improve engagement with services, and are supported by extensive research (NIH, 2010)

Effective Solutions

The research base is clear that effective strategies require housing first coupled with robust, voluntary, and when necessary, assertive services, rather than coercion or involuntary commitment:

1. Housing First: Provides immediate access to permanent housing without preconditions. Randomized controlled trials and longitudinal studies show that Housing First dramatically increases housing stability compared to treatment-first or shelter-based approaches (Tsemberis et al., 2004).
2. Integrated Supportive Services: To promote recovery and accountability, Housing First programs must pair housing with services such as mental health counseling, substance use treatment, medical care, and case management.
3. Assertive Community Treatment (ACT): For individuals with severe mental illness, ACT teams provide frequent, intensive, and community-based support, achieving higher treatment adherence, reduced hospitalizations, and improved housing retention without involuntary commitment (Phillips et al., 2001)
4. Harm Reduction Approaches: Evidence shows that harm reduction programs reduce overdose deaths, infectious disease spread, and improve engagement in treatment—directly addressing the EO’s stated concerns about public safety. 

Systemic Challenges

Current homelessness systems are under-resourced. Many communities lack sufficient affordable housing, case management capacity, and coordinated health services. These gaps leave individuals exposed to cycles of crisis, incarceration, and hospitalization. Accessible voluntary services are necessary but not sufficient; high-risk individuals may require more assertively delivered services to ensure both their safety and that of the community.

To the extent Housing First is not meeting its promise for the minority of the homeless population who are experiencing mental illness or SUD, it is due to lack of co-investment in services, not a failure of the model itself. The solution is more robust service-delivery--especially through ACT and permanent supportive housing--not a return to the dark days of mass institutionalization. 

Conclusion

The evidence indicates that public safety and community well-being are best supported by:

• Investing in Housing First and permanent supportive housing,
• Ensuring comprehensive, assertive voluntary services (including ACT),
• Maintaining and expanding harm reduction programs, and
• Addressing systemic barriers to affordable housing and health care.

Coercion, involuntary commitment, or criminalization of homelessness does not address the root causes and is consistently shown to worsen outcomes. A data-driven, humane approach requires substantial investment in housing and services that meet people where they are, protect civil rights, and promote long-term stability.