A recent NPR investigation shines a stark light on how psychiatric patients in the United States, particularly in Montana, become trapped in a relentless cycle of homelessness, fragmented care, and social exclusion. The story, centered on a woman known as K and told through her daughter L’s harrowing experience, reveals how insufficient mental health services, lack of stable housing, and bureaucratic gaps intertwine to keep vulnerable individuals on the margins of society. As Thailand grapples with its own rising numbers of unhoused people living with mental illness, the lessons from Montana’s crisis offer urgent warnings and valuable insights for Thai policymakers, health workers, and society at large (NPR, 2025).
K, aged 65, has lived without permanent shelter in Missoula, Montana for eight years, battling schizoaffective disorder—a condition characterized by intense mood swings and delusions. A critical but under-recognized symptom, anosognosia, leaves K unable to recognize her illness, leading her to refuse care even when it is available. Her daughter’s painful attempts to navigate the mental health system, bring her mother indoors, and regain some semblance of stability, highlight not just a personal tragedy but a systemic failing. Montana’s psychiatric infrastructure, strained by underfunding—including the 2017 Medicaid cuts—and the closure of facilities during the COVID-19 pandemic, buckled under rising need. This resulted in people like K cycling between jail, emergency rooms, and the state’s only psychiatric hospital, often without sustained improvement.
Background data links these local experiences to broader, persistent patterns. Research consistently shows the majority of people experiencing homelessness in both the US and Thailand have a far higher prevalence of psychiatric disorders than the general population (Awirutworakul et al., 2018; Wattanapisit et al., 2024). For instance, a systematic survey of unhoused people in Bangkok revealed that 76% had diagnosable mental illness, with rates of depression, psychosis, and substance use disorders many times higher than the general Thai population (Awirutworakul et al., 2018). Suicidal risk among Bangkok’s homeless reached a staggering 29%, in stark contrast to 1% in the general population. Substance abuse—a factor that often interacts with and exacerbates psychiatric symptoms—was also prevalent: nearly a quarter of those surveyed met criteria for alcohol dependence in the previous year.
The Montana case highlights that, even when mental health services exist, a lack of sustained follow-up, stable housing, or integrated support guarantees relapse. L’s experience in Missoula was one of scrambling: “It’s pretty painful on cold nights to have to not let somebody in because it will deteriorate your whole mental health and stability,” she admits tearfully. The pain is compounded by bureaucratic hurdles. After losing case management services due to budget cuts, K spiraled out of control. With nowhere to go, she was alternately rejected by shelters (side effects from medication, behavioral issues), arrested for trespassing, discharged too soon from the psychiatric hospital, and left to fend for herself. In one tragic bureaucratic misstep, hospital staff even administered the wrong medicine—a setback that cost months of progress.
Thai researchers have identified similar bottlenecks. A 2024 scoping review of 19 studies showed that most Thai people who become homeless do so due to a complex interplay of poverty, family breakdown, trauma, and—critically—mental illness (Wattanapisit et al., 2024). Once on the street, the challenges only multiply: lack of documents for health insurance, transportation barriers, experiences of stigma and discrimination, and a pervasive sense that the system is not set up to help. One study highlighted that among psychiatric patients admitted to a Bangkok hospital from the street, 64% were diagnosed with schizophrenia, and their stays lasted an average of 53 days, often followed by discharge to shelters or right back onto the streets (Wongjongrungruaeng et al., 2019).
The NPR story and Thai research make it clear: short-term “band-aids” like brief hospitalization or ad hoc shelter placement don’t break the cycle of psychiatric crisis and homelessness. In Montana, a recent legislative push to invest US$300 million into mental health reform stands as a beacon—but even this, experts warn, may be insufficient without strategic investment in housing. Ben Miller, a psychologist specializing in systemic reform, cautions: “If you just get someone stable housing, you can watch how their mental health, the benefits, go up overnight.” Yet securing such housing—whether in Montana or Thailand—remains a formidable challenge.
Thai society faces parallel pressures. According to the Community Organizations Development Institute, over 4,500 people experienced homelessness in Thailand as of 2022, with the majority concentrated in Bangkok, and the true figure likely undercounted (Wattanapisit et al., 2024). The Thai system provides universal health coverage, in theory granting all citizens (at least on paper) access to health services. But in practice, those without permanent addresses or ID cards find themselves excluded from care, echoing K’s plight in the US. Local studies emphasize that mental health resources are scarce on the ground, and case management—a critical service that keeps patients connected and compliant with care—remains limited by staffing and funding constraints (Awirutworakul et al., 2018; Wattanapisit et al., 2024).
Historical and cultural attitudes towards mental illness in Thailand further complicate matters. Stigma remains strong, and families often experience shame or feel compelled to hide an affected relative, as L did by withholding her mother’s name. Cultural expectations around family caregiving sometimes leave caregivers with debilitating emotional burdens; L eventually had to leave Montana for her own mental health, stating, “I also have to put myself first, too, because I don’t have anyone else doing that.” Thai caregivers, too, often shoulder these burdens in silence, with few avenues for respite or support.
Will policy reforms and investment fix the system? In Montana, new funds are set to expand group homes, create “step-down” facilities for post-hospitalization care, and bolster mobile crisis teams. But local officials and advocates are skeptical. Missoula County Attorney Matt Jennings warns, “If you just get out of a hospital setting… and you go back into a homeless situation… then the cycle repeats itself because there isn’t a long-term plan.” The situation in Thailand is similar: government agencies and NGOs often work in silos, and while some interventions (such as the Ministry of Human Security and Social Development’s “One Night Count” project) aim to quantify and help the homeless population (Bangkok Post, 2019), sustainable models for integrated care and stable housing remain few and far between.
So what is the way forward? International and local research point to several clear, actionable priorities. First, stable, supported housing is not a luxury—it’s foundational for mental health recovery. Evidence shows that the provision of case management, community-based psychiatric services, and employment support can help people reclaim independence and break the crisis cycle (Awirutworakul et al., 2018). Policies must be designed to ensure continuity between short-term crisis care and long-term, community-based solutions. Second, training for shelter staff, police, healthcare professionals, and social workers is critical. When service providers lack understanding of mental illness and trauma, patients fall through the cracks or are retraumatized by the system (Wattanapisit et al., 2024). Third, barriers to service access—such as lack of identity documentation or bureaucratic red tape—must be systematically removed, using outreach teams and innovative community-based models.
Finally, Thai society must address stigma, both at the institutional and community level. Real change will come not just from the Ministry of Public Health or social service agencies, but also from neighborhoods and temples willing to accept and help rehabilitate people with mental health needs. Programs that leverage Thailand’s traditions of communal support—perhaps by engaging monks, community leaders, and local health volunteers—could provide culturally resonant models for reintegration and care.
The story of K and her daughter L is a cautionary tale, but it is not unique. As economies stall and social safety nets strain from the pressures of inequality and urbanization, both the US and Thailand will see rising numbers of people like K unless urgent, integrated action is taken. For policy makers, health workers, and everyday Thais, the lesson is this: homelessness and mental health are not separate problems. Addressing them together, with compassion and coordination, is the only way out of the cycle.
For concerned Thai readers, practical steps include: supporting community organizations that provide case management and outreach to the homeless, lobbying local and national officials for more integrated mental health services, volunteering time or resources to shelters, and—perhaps most importantly—advocating for social inclusion and understanding for those living with mental illness. As the ancient Thai proverb goes, “น้ำพึ่งเรือเสือพึ่งป่า”—we all depend on each other to survive.
Sources:
- NPR: “How psychiatric patients get caught in a cycle of homelessness and spotty care”
- Awirutworakul T, et al. “Prevalence of psychiatric disorders in homeless population in Bangkok, Thailand”
- Wattanapisit A, et al. “Health-related issues of people experiencing homelessness in Thailand”
- Bangkok Post: “Seeking heartfelt care for the homeless”
- Wongjongrungruaeng T, Naowarat S, Kaewyot K. Journal of Somdet Chaopraya Institute of Psychiatry, 2019