Photograph by: Keck School News

A Man or A Statistic?

A figure by the name of Yoh resides under an underpass by the 110 freeway in Los Angeles, mere feet away from cars whipping past. He vacantly speaks of a 44-light-year-long piece of concrete and orders from the CIA that restrict him from eating until he has completed a mission. With ankles covered in dirt and hair pressed to his head, Yoh does not attempt to find himself food and water and smokes crystal methamphetamine [1]. 

Yoh is among 75,312 unhoused individuals in Los Angeles County, part of the larger 771,480 who live in the United States [2,3]. Living without a house means his life expectancy is, on average, 30 years shorter than his housed counterparts [4]. He faces a 3.5 times higher mortality rate and has likely endured an adverse childhood experience (ACE)—including but not limited to neglect, poverty, domestic violence, and familial suicide—which affects 90 percent of the homeless population [5]. He likely has a serious mental illness (SMI) and a substance use disorder, speculated to be present in half of the homeless population [6]. Like hundreds of thousands of unhoused individuals in America, he has no access to medical care: no health insurance, no primary care physician, and no first aid. He and many others remain alone, unseen, and untouched by a system that is too difficult to access. 

This is where street psychiatry has slowly entered the healthcare atmosphere, centered around the need for urgency and empathy to reduce homelessness in the United States.

What Is Street Psychiatry and What Is Its History?

Street psychiatry, or street medicine, provides immediate medical and behavioral health care to unhoused individuals, aiming to reduce substance abuse and address the housing crisis in the United States. Teams of psychiatrists, primary care physicians, community outreach workers, and nurse care managers provide evaluations and voluntary treatment to unhoused individuals in highly personalized environments. Although this typically includes antipsychotic medications and opioid treatment injections, the primary focus is building trusting relationships – an effort that takes months or years to develop in a broken system. All care is voluntary, except for when teams see an urgent need, in which they can petition the court for involuntary treatment [6].   

Deemed a new and alternative strategy for addressing homelessness in the United States, the first organized movement in street psychiatry originated in 1992. Dr. Jim Withers, working then in Pittsburgh, Pennsylvania, aimed to create a more accessible healthcare system for a typically marginalized community – the homeless. Centering his operations around holistic patient care, he established Operation Safety Net, the flagship program that later evolved into the Street Medicine Institute (SMI), known today. As the program spread nationally, he founded the International Street Medicine Symposium in 2005 and, working in tandem with the SMI, has established programs in more than 85 cities worldwide [7]. 

County sales taxes, state funding, grants, and donors fund most street medicine programs, shielding them from government policy. However, recent efforts by Trump to defund the Department of Housing and Urban Development pose risks. A decreased availability of housing for the homeless undermines the ultimate goal of street medicine, forcing teams to care for patients for longer periods [8]. However, the Trump administration’s focus on addressing shortages in mental health and substance abuse services could be beneficial in ensuring that expanded street medicine teams receive the necessary resources [9].  

How Is Street Psychiatry Present in the Los Angeles Community?

In Los Angeles, street-medicine-centered residency programs started in 2017 at the University of California, Los Angeles, following the establishment of the county’s Office of Diversion and Reentry in 2015. UCLA faculty incorporated studies in criminal justice, homelessness, global mental health, and peer support services while collaborating with law enforcement, the criminal justice system, legislators, and others to equip residents with a mental health-centered approach to patient care [10]. Additionally, the University of Southern California’s Keck School of Medicine mandates that residents complete an eight-week course focused on street medicine, with options for additional coursework if desired [11]. 

In 2018, the Los Angeles County Mental Health Clinic on Skid Row administered its first injectable to a homeless woman. This followed a lengthy process of daily visits providing essential items, oral antipsychotic medication, and ultimately, injecting a month-long lasting opioid into her arm behind a telephone pole. Los Angeles County’s Homeless Outreach and Mobile Engagement program (HOME) has since expanded this effort, deploying 18 teams during weekdays to visit over 1,700 homeless individuals in an attempt to persuade them to accept antipsychotic medications. As of 2023, the operation has a budget of $43 million and employs 223 staff members [12].  

In light of this expansion, many question its reliability. 

Is Street Psychiatry Truly Effective and Efficient?

Critics argue against the standardization and effectiveness of street psychiatry. Although HOME reported that 22 percent of treated patients ended 2023 in stable housing, little research has been conducted to prove that street psychiatry is more effective than Housing First (HF) interventions, which offer immediate and permanent housing with no prerequisites [13]. A study by the National Institute of Health in 2019 revealed that 80 percent of participants remained housed after one year, indicating strong retention, compared to only 40 percent in programs lacking initial permanent housing. Furthermore, HF initiatives reduced emergency room visits by 34 percent and hospitalizations by 29 percent, applying the strategy of spending money to save money [14]. By providing houseless individuals with immediate housing, long-term costs significantly decrease, while street psychiatry has not been sufficiently researched to demonstrate that its benefits outweigh its costs. Additionally, street psychiatry places an even larger burden on the existing psychiatry shortage, as the number of psychiatrists is expected to decline by 20 percent while demand rises by 3 percent by 2030 [15]. 

More criticism lies in the inherent lack of standardization. Every patient is met in a highly personalized and individual setting, approached wherever they are on the street by various staff members, and treated over various time lengths from months to years. There are no written rules for when individuals should be involuntarily helped or detained and transported to higher aid, making it difficult to assess ethical and practical lines of care [16]. However, quick examinations are typically given using the flowchart below, providing a semblance of standardized care [17]:

Logistically, street psychiatry faces challenges in securing long-term care for patients due to funding and identification issues. Most individuals lack an address, transportation, identification, or phone number, making it increasingly difficult to connect them with regular care and treatment programs necessary for their sustainable health [18]. This challenge is strongly linked to inadequate funding, as many street psychiatry teams rely on grants and donations from state and federal governments rather than consistent financial support [19]. Although the nationwide movement is growing significantly and proving effective, the absence of a centralized organization complicates cohesive expansion in the future. 

Where Do Its Ethical Problems Lie?

Additionally, significant ethical questions arise from the practice of street psychiatry. Rapid medical diagnoses coupled with fewer resources than hospitals offer can lead to improper, inadequate, or incorrect care. Street psychiatry teams often lack complete patient histories and may be ill-prepared to assist individuals, potentially resulting in inaccurate diagnoses [20]. This situation raises concerns about provider liability, particularly concerning the Good Samaritan Law, which allows individuals to help others in emergencies while protecting them from the legal consequences of unintentional errors. If psychiatrists inadvertently harm patients, will the Good Samaritan Law cover them? For instance, a ruling in New Jersey found that the Good Samaritan Law “stops at the door of the hospital,” suggesting it might not apply to street psychiatry teams [21]. 

Regarding the administration of drugs, the use of sedatives and opioids poses risks, given the daily dangers of life on the streets. Individuals must remain vigilant to survive, protect their possessions, and stay safe. Many resort to meth to stay awake at night and opioids to sleep during the day, leading to a nocturnal lifestyle aimed at safeguarding their well-being [22]. Although street medicine is beneficial, the disruption to these typical routines introduces inherent risks. 

How Does Policy Disagree With Street Psychiatry?

The most pressing ethical dilemma involves consent and the voluntary treatment of patients. While they may agree to further treatment or drug doses, many are not sober when asked. It is crucial to differentiate between impaired consent and informed consent, as impaired decision-making could raise concerns about coercion. Those experiencing homelessness might feel pressured to accept treatment, whether sober or not, due to receiving food, supplies, and the promise of housing. Furthermore, the Supreme Court's decision in Grants Pass v. Johnson (2024) permits federal officials to arrest individuals sleeping outside, even without a safe alternative, raising additional coercive issues [23]. Would individuals be accepting medical treatment out of fear of punishment or out of genuine, sober desire? This situation creates a fine line between beneficence and autonomy, where the persistent efforts of street psychiatry teams might be perceived as a disregard for the individual autonomy of those experiencing homelessness. 

Recent policies may severely undermine street psychiatry efforts. On February 11, 2025, the Fremont City Council passed an anti-homeless law, well-intentioned yet laden with vague language. One provision states that anyone “causing, permitting, aiding, abetting, or concealing” homeless individuals faces a $1,000 fine and up to six months in jail, effectively diminishing the authority of street psychiatry teams and others seeking to help the homeless. While Mayor Raj Salwin asserted that the ordinance “does NOT prevent organizations from providing food, water, or essential services to unhoused individuals,” the overwhelming sense of fear it generates is significant [24]. Churches hesitate to hand out care bags for fear of punishment, and street psychiatrists face a similar dilemma. Although the ordinance applies only to Fremont, it presents state and nationwide risks to the altruistic efforts of street psychiatry throughout the United States, as well as wider trends against aiding the homeless. Conflicts with federal officials have previously occurred, with officers telling street medicine teams that their work is illegal, and new legislation like this would only escalate tensions between citizens and officials [25]. 

Overall, street psychiatry offers a highly personalized approach to addressing the most severely underrepresented population in the nation. It reaches a unique demographic by administering opioids publicly, making daily or weekly visits to individuals on the streets, and building long-term relationships aimed at mitigating the homeless crisis in the United States. Although extremely well-intentioned and largely successful, standardizing treatments and practices is essential for sustaining street psychiatry. While less likely under the Trump presidency, federal government support for research, funding, and the development of this nationwide movement is necessary to effectively and genuinely assist this marginalized population in this way. 

And what about Yoh? His name is Eric Covington. He has moved into a county-run hotel room providing temporary housing, under the care of nurses who supply food and medication. He aims to make friends and improve his life [26]. Ultimately, street psychiatry – with all its logistical, funding, and ethical challenges — has transformed his life completely, as well as the lives of many others. Street psychiatry is a crucial aspect of modern medical practice. By advocating for greater state and federal support, much more good can be achieved to assist the hundreds of thousands currently without homes.