Autonomy and Ethical Dilemmas in Psychiatry

Presented by:
Emma Lo, MD
Assistant Professor of Psychiatry
Medical Director, Street Psychiatry Team
Yale School of Medicine


Faculty Disclosure: Dr. Lo has disclosed that she has no relevant financial relationships. No one else in a position to control content has any financial relationships to disclose.

Conflict of interest information for the CME Advisory Committee members can be found on the following website: All relevant financial relationships have been mitigated.


Release Date: April 25, 2023
Expiration Date:  April 24, 2026

Target Audience: All physicians; LCSW, LMHC, LMFT licensed only in Florida


Learning Objectives:

As a result of participation in this activity, participants should be able to:

  1. Explain the history of the deinstitutionalization as it relates to homelessness in the U.S.
  2. Describe current trends and evidence related to involuntary commitment.
  3. Explore ethical principles of autonomy, non-maleficence, beneficence, and justice as they relate to the practice of street psychiatry, through examples such as involuntary hospitalization and conservatorship.
  4. Discuss how interventions such as street psychiatry and others can provide care for this population while respecting autonomy.


Requirements for successful completion: Certificates are awarded upon successful completion (80% proficiency) of the post-test.

Accreditation: The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit: The University of Florida College of Medicine designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Resource(s) for further study:

  1. Lam JA & Rosenheck R. 1999. Social support and service use among homeless persons with serious mental illness. International Journal of Social Psychiatry, 45(1), 13-28.
  2. McQuistion HL, Finnerty M, Hirschowitz J, Susser ES. 2003. Challenges for psychiatry in serving homeless people with psychiatric disorders. Psychiatr Serv, 54(5):669-46. Doi: 10.1176/ PMID: 12719496.
  3. Gutwinski S, Schreiter S, Deutscher K, Fazel Seena. 2021. The prevalence of mental disorders among homeless people in high-income countries: An updated systematic review and meta-regression analysis. PLoS Med, 18(8):e1003750. Doi: 10.1371/journal.pmed.1003750. PMID: 34424908.
  4. NHCHC. 2014. Exploring the Experiences of Violence Among Individuals Who Are Homeless Using a Consumer-Led Approach. Violence and Victims, 29(1).
  5. Sullivan G, Burnam A, Koegel P. 2000. Pathways to homelessness among the mentally ill. Soc Psychiatry Psychiatr Epidemiol, 35(10):444-50. Doi: 10.1007/s001270050262. PMID: 11127718.
  6. Roncarati JS, Baggett TP, O’Connell JJ, Hwang SW, Cook EF, Krieger N, Sorensen G. 2018. Mortality Among Unsheltered Homeless Adults in Boston, Massachusetts, 2000-2009. JAMA Intern Med, 178(9):1242-1248. Doi: 10.1001/jamainternmed.2018.2924. PMID: 30073282.
  7. Levitt AJ, Culhane DP, DeGenova J, O’Quinn P, Bainbridge J. 2009. Health and Social Characteristics of Homeless Adults in Manhattan Who Were Chronically or Not Chronically Unsheltered. Psychiatric Services, 60(7):978-981.
  8. Montgomery AE, Szymkowiak D, Marcus J, Howard P, Culhane DP. 2016. Homelessness, Unsheltered Status, and Risk Factors for Mortality: Findings From the 100,000 Homes Campaign. Public Health Rep., 131(6):765-772. Doi: 10.1177/0033354916667501. PMID: 28123222.
  9. Nyamathi AM, Leake B, Gelberg L. 2001. Sheltered Versus Non-Sheltered Homeless Women: Differences in Health, Behavior, Victimization, and Utilization of Care. Journal of General Internal Medicine, 15(8):565-572.
  11. Bradford DW, Gaynes BN, Kim MM, Kaufman JS, Weinberger M. 2005. Can Shelter-Based Interventions Improve Treatment Engagement in Homeless Individuals with Psychiatric and/or Substance Misuse Disorders?: A Randomized Controlled Trial. Medical Care, 43(8):763-768.
  12. Carter J, Zevin B, Lum PJ. 2019. Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin in San Francisco. Addict Sci Clin Pract., 14(1):20. Doi: 10.1186/s13722-019-0149-1. PMID: 31060600.
  13. Buhrich N, Teesson M. 1996. Impact of a psychiatric outreach service for homeless persons with schizophrenia. Psychiatr Serv., 47(6):644-6. Doi: 10.1176/ps.47.6.644. PMID: 8726495.
  17. Kisley SR, Campbell LA, O’Reilly R. Compulsory Community and Involuntary Outpatient Treatment for People with Severe Mental Disorders. Cochrane Database Syst Rev., (3): CD004408. Doi: 10.1002/14651858.CD004408.pub5.
  18. Werb D, Kamarulzaman A, Meacham MC, Rafful C, Fisher B, Strathdee SA, Wood E. 2016. The Effectiveness of Compulsory Drug Treatment: A Systematic Review. Int J Drug Policy, 28:1-9. Doi: 10.1016/j.drugpo.2015.12.005. PMID: 26790691.
  20. Aggarwal NK, Rosenheck RA, Woods SW, Sernyak MJ. Race and long-acting antipsychotic prescription at a community mental health center: a retrospective chart review. J Clin Psychiatry. 2012 Apr;73(4):513-7. doi: 10.4088/JCP.11m07161. PMID: 22579151; PMCID: PMC3885178.
  21. Allen M, Smith VF. Opening pandora’s box: the practical and legal dangers of involuntary outpatient commitment. Psychiatr Serv. 2001 Mar;52(3):342-6. doi: 10.1176/ PMID: 11239102.
  22. Baggett TP, Hwang SW, O’Connell JJ, et al. Mortality Among Homeless Adults in Boston: Shifts in Causes of Death Over a 15-year Period. JAMA Intern Med. Feb 11, 2013; 173(3): 189–195.
  23. Baggett TP, O’Connell JJ, Singer DE, and Rigotti NA. The Unmet Health Care Needs of Homeless Adults: A National Study. American Journal of Public Health.  July 2010, 100(7): 1326-1333.
  24. Baxter AJ, Tweed EJ, Katikireddi SV, Thomson H. Effects of Housing First approaches on health and well-being of adults who are homeless or at risk of homelessness: systematic review and meta-analysis of randomised controlled trials. J Epidemiol Community Health. 2019 May;73(5):379-387. doi: 10.1136/jech-2018-210981. Epub 2019 Feb 18. PMID: 30777888; PMCID: PMC6581117.
  25. Beletsky L, Ryan EJ, Parmet WE. Involuntary treatment for substance use disorder: A misguided response to the opioid crisis. Harvard Health Blog. 2018 Jan.
  26. Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, Koepsell TD. Release from prison–a high risk of death for former inmates. N Engl J Med. 2007 Jan 11;356(2):157-65. doi: 10.1056/NEJMsa064115. Erratum in: N Engl J Med. 2007 Feb 1;356(5):536. PMID: 17215533; PMCID: PMC2836121.
  27. Borrell LN, Diez Roux AV, Jacobs DR Jr, Shea S, Jackson SA, Shrager S, Blumenthal RS. Perceived racial/ethnic discrimination, smoking and alcohol consumption in the Multi-Ethnic Study of Atherosclerosis (MESA). Prev Med. 2010 Sep-Oct;51(3-4):307-12. doi: 10.1016/j.ypmed.2010.05.017. Epub 2010 Jun 8. PMID: 20609433; PMCID: PMC2939242.
  28. Christensen RC. Psychiatric Street Outreach to Homeless People: Fostering Relationship, Reconnection, and Recovery. Journal of Health Care for the Poor and Underserved 2009; 20:4, 1036-1040.
  29. Humphrey N. “House Calls to the Homeless.” Vanderbilt Medicine, 2016.
  30. Koh K, Racine M, Gaeta JM et al. Health Care Spending And Use Among People Experiencing Unstable Housing In The Era Of Accountable Care Organizations. Health Affairs.2020 39(2).

If you have any questions please feel free to contact Nancy Boyd at (352) 594-4298 or at