I just discovered this Community Psychiatry Podcast site today. A couple of days ago Dr. Emily Morse, DO, of The University of Iowa Health Care gave a 20-minute interview that outlines how the psychiatry department leverages community psychiatry outreach to address the challenges those experiencing homelessness face.
Introduction: “Emily Morse, DO, is a Clinical Associate Professor of Psychiatry at the University of Iowa where she was first drawn to community-based care during her residency training. Her current clinical work spans a variety of settings which include outreach clinics embedded within local permanent supportive housing programs in partnership with Shelter House in Iowa City—an organization that provides comprehensive support services to help individuals move beyond homelessness. She also works as part of interdisciplinary teams that reach patients across Iowa, including one focused on individuals with intellectual and developmental disabilities, and another providing reproductive and perinatal mental health care. Along with her clinical work, she is active in medical education as a psychiatry clerkship co-director, and she enjoys working alongside residents and fellows while aiming to provide accessible, collaborative, and relationship-centered care.”
Dr. Morse provides a view of psychiatry that goes beyond the idea of scheduled appointments in the psychiatry clinic.
This is also a great way to get beyond the politicization of this issue we typically hear about in the national and local news almost every day.
I’ve been looking for other ways that Iowa addresses mental illness and its impact on homelessness and other adverse outcomes since my last post on the issue.
It turns out that, despite Iowa ranking 51st out of all U.S. states for the low number of psychiatric beds according to the Treatment Advocacy Center statistics (in 2023, it had just two beds per 100,000 patients in need), a new mental health court established in in May of 2023 has made substantial progress in reducing the number of crisis contacts, psychiatric hospitalizations, and days in the hospital. Arrests, jailings, and days in jail were also reduced.
Participants in the new program include the University of Iowa Health Care, Iowa City VA Hospital, the Abbe Center, Guidelink Center, National Alliance for the Mentally Ill (NAMI), Shelter House, and several other mental health service agencies in Johnson County.
The Johnson Mental Health Court continues to operate since June of this year when the pilot program’s funding from the East Central Iowa Mental Health Region was supposed to have ended on June 30, 2025, due to the change in mental health regions. This is a program for patients under involuntary mental health commitment that avoids incarceration and placement in a state psychiatric hospital.
This civil mental health program didn’t exist until well after I retired and I hope for its continued success.
After I read Dr. Dawson’s post today “More on homelessness and violence as a public health problem,” it got me thinking about what the situation on homelessness of people with mental illness and substance use disorder is here in Iowa.
First, I looked at the 2024 Iowa Homelessness Needs Assessment, which is a thorough report you can download if you need it. It’s a 23-page pdf document which doesn’t mention the intersection with the homeless mentally ill until almost the very last page. It gets mentioned in the section subtitled “Improve Coordination With Adjacent Systems”:
To end or substantially reduce homelessness, a coordinated response is needed that aligns the resources in adjacent systems with CoC resources and housing. Homelessness is often caused by and/or exacerbated by the inability of public support systems to address the complex needs of people in extreme poverty experiencing housing crises. These systems include education, hospitals, behavioral health, criminal justice, and child welfare. Engagement and service delivery approaches need to be responsive to the particular needs of people at imminent risk or experiencing literal homelessness. More responsive adjacent systems will provide specialized engagement, enrollment supports, discharge planning, and coordination with CoCs in each region.
Typically, this kind of document makes me thirsty for a more granular, human connected account of what kind of person actually becomes homeless. Are they always dangerous? The answer is “no.”
Actually, there’s this human-interest Iowa’s News Now story published December 27, 2024, “A Closer Look: U.S. and Iowa homelessness reach record highs” (accessed July 28, 2025). It’s about a real person who became homeless despite being a University of Iowa graduate.
People become homeless for many reasons. I just want to mention resources that are available in Iowa that could be helpful. The website Homeless or At-Risk of Homelessness presents the idea that “Sometimes, life takes an unexpected turn. People face hardships and turn toward their communities for support.”
There are some people who struggle with mental illness and substance abuse and as a consequence of those challenges become homeless, as the Iowa Homelessness Needs Assessment above points out.
One resource I think is important is The University of Iowa’s Integrated Multidisciplinary Program of Assertive Community Treatment or PACT program. It’s an evidence-based treatment model that’s been around for decades in many locations in the U.S.
There’s also an Iowa Health and Human Services program called PATH (Projects for Assistance in Transition from Homelessness) to help homeless adults with mental illness, substance abuse and trauma.
This was just a quick and admittedly superficial summary of what Iowans have been doing about the homelessness crisis. It really takes a village.
I want to give a shout out to Dr. George Dawson for his post today “The Autocratic Approach to Homelessness” in reference to President Trump’s most recent executive order, “Ending Crime and Disorder on America’s Streets.” As a retired psychiatrist, I look back and remember seeing the problem of the homeless mentally ill a lot. You can read my take on it from last summer’s posts:
The homeless guy camped next to the busy street just outside of our hotel is still here. I’m going to call him Bob because it’s awkward to keep calling him “the homeless guy.” I haven’t met Bob yet, but Sena got him some water. She had to give it to the hotel resident who so far is the only one who has been able to communicate with him.
Sena and I talked about what might be done for Bob. She noticed that his face was sunburned bad enough to cause the skin to peel off. Could a case be made for his being a danger to himself?
Of course, you could guess this issue would come up because I’m a retired psychiatrist. As an aside, I found an article published in the Daily Iowan early this year. The author interviewed several residents of a homeless camp who were displaced after a fire and subsequently the owners of the land closed the camp.
The homeless people at the camp were articulate and open to interview. Some of them were clearly choosing to be homeless and able to state how and why they did.
Bob might not be articulate enough to do that. He spends most of his time lying on the pavement with his blanket over him. It’s sometimes hard to tell if he’s out there until he moves. When he’s up, he usually stands up and waves his arms back and forth or sits on the grass. Occasionally, he moves in ways suggesting he’s acting out some kind of conversation with an invisible person.
A police officer stopped by, spoke briefly with Bob, and left. A woman stopped by and tried to help him clean up his room, so to speak. She picked up some of his trash and put it in a bag. She tried to get him to help, but he didn’t seem to understand.
What about Bob? Is he a danger to himself or others? Is he incapable of taking care of his basic self-care needs? Sooner or later, this would come up because the mental health laws would come into play. There are many homeless people out there living under bridges and camps. We’ve seen them when we go out for walks. Not all of them are definable as mentally ill.
There is guidance on the web about how to pursue a court-ordered psychiatric evaluation. I’m a retired psychiatrist and often was involved in those circumstances.
One way it works is that two people who are acquainted with the person go to the courthouse and complete paperwork to have someone ordered by a judge to be taken to the hospital for a mental health evaluation. If the judge signs an order, then typically the police would pick the person up and take them to the local emergency room. There aren’t vans with mental health professionals roaming the city looking for potential patients.
A psychiatrist performs a comprehensive mental health evaluation and later presents the report and testifies at a scheduled hearing. Attorneys are involved and give testimony for and against civil commitment. The patient also can speak. If the patient is court-ordered to inpatient treatment, that treatment is provided in the hospital usually. Periodic reports must be submitted to the court. Some people who are the objects of these interventions get better. Others don’t.
What’s missing here? You must at least know his real name to file for legal hold order. Although Sena says she saw Bob take out a cell phone, it’s not clear he knows how to use it or whether it even works. The only people who interact with him are those who are driving by and who show sympathy by buying food and water and other items for him. He usually tosses the empty water bottles in the parking lot where he sleeps. The police evidently didn’t think he needed an intervention from their perspective.
We don’t even know his real name. I haven’t tried to talk to him. I’ve never seen him act in a threatening way to anyone. Bob takes up one parking space and keeps his belongings within it. He usually lies under a blanket, often for several hours at a time. Bob doesn’t panhandle and I doubt he’s capable of that.
We can see the man from our hotel window. We assume he’s homeless. He has a small area where he sits on the curb next to the street. He does this most of the day. He has a blanket and a few other loose items which sometimes are strewn on the sidewalk or the grass.
Even in 90-plus heat, he’s out there, sometimes standing beneath a small tree, presumably for shade although it’s inadequate. He waves his arms around in what looks like a futile attempt to cool himself. He might just be restless. Other times he sits on his blanket. Occasionally, people stop their cars and seem to be trying to communicate with him. He most often ignores them.
One of the hotel residents approaches him sometimes. It looked like he gives him something (probably a cigarette). Once, the homeless man left his station by the street and walked over to the front of the hotel, waving his arms, seemingly because the hotel resident was speaking to him. We couldn’t see what happened after that, but when he returned to the street, he lit a cigarette. We also saw he accepted fluid, maybe a can of soda.
Later, some people in a car gave him something they bought in a nearby drive-up fast-food joint. He threw out the ice from his drink, which he didn’t consume and sprinkled the fluid on his arms. The people left and returned later with several items they gave him. Some of it looked like more water, which he again poured on his arms. There was a backpack or something like it. He didn’t seem to know what to do with it.
He couldn’t ignore them when they try to help him (water, food, etc.). One person tried to help him clean up his little camp by picking up his trash. The police came out to check on him. We couldn’t hear the short conversation. After she left, he continued to toss his water bottles and other items into the parking lot. He sleeps on the pavement.
This reminded me of a couple of times when I’ve seen hobos. I don’t see the homeless man as a hobo. The term “hobo” is not synonymous with homeless, vagrant, or tramp. Hobos prefer not to have a home, travel around to find work, may still ride the rails to get around, and don’t see themselves as tramps.
As a young man, I worked for consulting engineers as a draftsman and survey crew worker in Mason City. This was in the 1970s. We traveled to outlying cities. One day, we went to Britt for a job. It was during the Britt Hobo Days Convention. It was not the first time I ever heard of it.
Funny thing, I thought I recognized one of the hobos in the café where we got coffee. He was wolfing down a big breakfast. When he was finished, he left in a hurry. I just assumed he was a hobo in town for the festivities. But he looked so familiar.
And suddenly it dawned on me. He had been a kindergarten classmate of mine. I couldn’t recall his name, but it was him.
Another memory that occurred to me was much later in my life, when I was a psychiatrist and co-attending on the medical-psychiatry unit in University Hospital in Iowa City. We admitted a patient who had been found walking around and around in a circle in the street, and seemed confused. Evidently the patient had an acute medical problem and no diagnosable psychiatric illness.
The patient identified as a hobo and was proud of it. The person was polite, grateful, and cooperative. The person refused any help from us beyond help for the acute medical problem. We discharged the person to the street.
Hobo life is different nowadays, I gather. Many have cars and phones. If you look carefully at their photos on the Britt Hobo Days web site, they don’t make me think of homelessness or mental illness. They have made a choice.
On the other hand, homelessness is often not a choice and severe mental illness is not uncommon. There is a homeless shelter in Iowa City, and the resources include a supportive community living program for those who struggle with mental illness. One member of the board of directors is a psychiatrist. Not every homeless person wants to go there. The University of Iowa Health Care has an Integrated Multidisciplinary Program of Assertive Community Treatment (IMPACT).
Go Retire Psychiatrist 