What are your thoughts? How much is homelessness linked to mental health? What do you think the barriers are to addressing homelessness? – Jay
Homelessness is rampant in the US with more than a half million people on the streets or in shelters. Most are individuals (70%) with people in families making up 30% of the homeless population. Unaccompanied youth under the age of 25 comprise about 6% of the homeless population.
There is a revolving door between homelessness and jail. Homeless persons with mental illness often go in and out of jail. Research estimates that 30% of homeless people suffer from mental illness.
But a study conducted by the L.A. Times in LA County found about two thirds of homeless persons had either a mental illness or a substance abuse disorder. And, people who have been incarcerated are almost ten times more likely to be homeless than the general public.
The federal government has allocated $1.1 billion worth of housing vouchers through the American Rescue Plan Act. As reported in the LA Times, while California has the worst housing crisis in the US, the state has only used 45% of the available vouchers. Los Angeles at less than 25% and San Francisco at less than 40% are offset by the dramatic data from San Diego. San Diego has used 100% of its emergency housing vouchers since June 2021.
What is the secret? San Diego streamlined and minimized the number of agencies that an individual has to deal with to apply for a voucher. Second, San Diego calculates how much the vouchers are worth on a neighborhood-by-neighborhood basis rather than using a flat rate for the entire city. Thus, the vouchers are more flexible.
We seem to have the resources to address homelessness. Effective housing placement reduces the jail population and by incorporating access to mental health services, we can complete the circle and slow down the revolving door of homelessness and jail.
Improving the homelessness crisis and access to mental health services can benefit from refining and organizing the resources so they become more integrated and effectively utilized by those in need.
That said, there is certainly an overwhelming demand for mental health services that falls disproportionately on government. Government facilities deal with the most violent and difficult cases and deserve more credit for what they do.
Written by Dr. Jay Slosar
Commentators
- Adam Nelson
- Bernard Douglas, MA, LMFT
- Candance Camper
- Dr. Deme Hill, D.P.A.
- Dr. Ken Lang
- Dr. Jay Slosar, Psychologist
- Eileen Frere
- Evelynn Moon
- Jason Frye
- Joseph Klunder
- Julia Overlin, MS LPCC NCC
- Linda Simon
- Marcia Segura
- Matthew Silver, CCEO, Esq.
- Michele Bratina
- Pauline C. Reich
- Stephen Scott Giem BS
- Susan Price
- Susanna Marshland
- Terri Eggers
- Valerie Cartonio
Working with dual and triple diagnosed undomiciled people in NYC several decades ago one theme was repeatedly echoed…without community there is no hope, there is no anchor to root people housing or away from SA. SA and other addictions are symptoms of homelessness but not causes; mental illness is evidence of untreated treatable conditions, they are symptoms of neglect by our society…if you can’t make people feel seen you have no relationship to build upon. There is a line from a Canadian movie “The Quarrel’ one man protests to another ‘How can you say that, I love you?’ and the other rebuffs with ‘Love me? How can you say you love me when you don’t even know what hurts me?’
It bothers me we build climate controls storage units for our stuff, but leave people on the street. Our States each need to prioritize the needs of those with mental health needs, and formerly incarcerated that have been stigmatized.
While there is not one correct address to address this crisis, many have responded that housing is the main answer. I would say that it is much more than housing. It is systems and policies that need to be changed. No amount of housing will solve this problem. Counties never stepped up as they were supposed to when deinstitutionalization occurred. The State of California uses funding on bullet trains and other similar programs instead of funding needed mental health treatment, substance abuse treatment and improved services in our criminal system. Without addressing the root causes of homelessness, nothing will change from where we are today. We have as severe of a drug problem today as when we had a Covid problem, but it is not being recognized as such.
In my experience, the intervention that is most effective in longterm prevention of homelessness is permanent supportive housing. Many cities are offering housing vouchers, honestly, because they are a LOT less expensive than permanent supportive housing and it allows the city to say "Look how many people we housed!". What they don't tell you is almost all of those people return to homelessness when the vouchers expire in 1-2 years. In San Francisco, it is simply not possible for a person to go from unemployed and homeless to earning enough money to pay market rate rent in 1-2 years. Average rent in SF for a one bedroom apt right now is $2950. Think about how a person who *maybe* has a high school education is going to figure out how to earn enough to pay that rent in 1-2 years. It doesn't happen. What does happen is that the person gets evicted when the voucher expires and then they lose hope. I've seen it over and over. They lose hope. They think "Well, I guess I'm never going to be able to make it. Even with help I couldn't make it." It is a HORRIBLE thing to watch happen. Permanent supportive housing is the only thing that actually works to prevent longterm homelessness.
Having worked largely with individuals managing severe mental illness I have seen firsthand the stressors on many of them as they try to balance work, life, family, trauma, addiction.... These are many moving parts impacting ones ability and attempts to maintain a level of stability most would consider adaptive. Having said that, our medical model in my opinion, is broken. It attempts to help though allowing individuals who do not wish to receive the help, think they do not need the help, think the medicines given them "are trying to poison them," prevent them from receiving the care being put in place and paid for by tax dollars. Allowing those not ready to leave, to leave Against Medical Advice (AMA) simply because they can, negates their role in ensuring the best care possible. I believe there should be an Appeal Board if someone wants to leave AMA to reassess and discuss "What brought you here?" for a reality check on the efficacy of staying versus being sent right back out into the throes that brought them there. Shelters are a great concept, however the limitations put on "no animals" , "can only stay X days", etc are not showing the truest empathy for those they're supposed to be there to help.
I'm adding a recent discovery of another major crisis, many may not be aware of: https://consumer2savlives.wordpress.com/2023/01/28/nationwide-fentanyl-used-with-dog-tranquilizers-to-eat-the-flesh-of-drug-users-now-needing-amputations/
There are many barriers to addressing homelessness, and one person, one organization, one government cannot address them all, its like looking through a prism, for as many reasons persons become homeless, we need just as many solutions. In addition, active substance abuse can be considered a disability, so I wanted to make sure thats noted. Homelessness can be linked to mental health, however, mental health can be improved with a home. There is a lot of work yet to be done to solve homelessness!
It's complex to consider what would help all three of these huge systems (housing providers, mental health/substance use providers, and the criminal justice system) to better meet the needs of our society, both separately and in coordination with one another. It's made more complex by the myriad individual, social, environmental, and institutional factors that contribute to homelessness, mental illness, and incarceration. Anyone who has worked with houseless people can't help but observe that there's a bidirectional relationship between housing status and mental health. Streamlining systems can be helpful (as long as the coordination really works -- I've seen some information-sharing/IT disasters), although limiting access points to improve efficiency can sometimes have the unintentional effect of excluding groups that don't feel culturally welcome at those points (I know of many homeless young adults who avoid seeking help at entry points that serve an older adult population -- they feel out of place).
Well written thoughtful article. In terms of the large population of mentally ill who are homeless, I feel that having treatment centers to serve and protect these folks would be a good start. LA used to have state run psychiatric hospitals but most no longer exist today. Adequate care is essential to mental health and also the dignity for this population. That being said, I feel that the progressive ideas involved in social justice go way too far. We have too many dangerous criminals on the streets because the DA refuses to prosecute. There is a correlation between mental illness and some criminal behavior but that does not or should not give people who break the law a free pass. Coddling criminals is not the answer to this issue. To make our cities safe, it is imperative to have affordable housing, andaccess to mental health . It also should not be open ended. The goal should be to help these people become able to get employment, and facilitate the entry into society as an independent human being. Veterans are another story… they deserve unlimited assistance for their service and trauma they endured
Dr. Jay Slosar, Psychologist Dr. Slosar is a very thoughtful, intelligent man. It shows in this article. I have worked with homeless, myself. I agree the first step is helping them with so many unmet mental health needs. We need to remember that these people are someone's Veteran, child, brother, sister, relative, and friend. If we can just get these people healthy and at productive jobs, it can change the entire course of their life. I recently wrote an article about it: https://www.latimes.com/socal/daily-pilot/opinion/story/2022-12-29/commentary-long-term-community-efforts-needed-to-return-life-to-normal#nt=0000016b-e17a-db3b-afeb-f7ff952f0003-showMedia-liI9promoMedium-7030col1nt=0000016b-e17a-db3b-afeb-f7ff952f0003-showMedia-liI9promoMedium-7030col1
Thank you, Dr. Slosar. We continue to see the overreliance on county jails/departments of corrections, as they struggle meeting the needs of citizens with mental illness, many of whom are without housing. Although communities everywhere have been making some progress in relation to reducing stigma as it pertains to people with mental illness, there is still so much work that needs to be done in advocacy and education. This is such a profound conversation that must continue, and real (feasible) solutions are necessary. First, there needs to be considerable "buy-in" from all stakeholders, specifically those in leadership and administrative roles; we have seen some cultural shifts in law enforcement and other justice-serving agencies, and therapeutic jurisprudence, positive criminology, and trauma-informed perspectives are leading philosophies in many spaces. Still, affordable housing and other community-based needs are desperately lacking, and policy changes must be informed by current research.
Would have liked to have seen the information that the article to which the link "San Diego streamlined and minimized the number of agencies" would have taken me to learn more about their experiences. Having said that, historically, there have been studies that showed that Supportive Housing has been the most successful solution because it has shown to be effective and (more importantly) cost effective. A social services study in NY in the 90s (I believe) estimated that supportive housing for a homeless person cost less per day than a stay at Riker's Island. Somehow, that messaging has gotten lost. Also, I cannot agree with the last statement about government deserving more credit. What I assume San Diego has done was to remove much of the bureaucracy in addressing the problems of homelessness and mental illness. In my experience government bureaucracy (and ill-advised policy) has historically been a major contributor to the problems of homelessness and mental illness.
Very well written and excellent data points. Mental illness certainly seems on the rise. There's plenty written about causes of homelessness, but I'd add that even in a housing crisis like here in CA, putting people into substandard code-violating housing is not the answer or acceptable. Let's make sure our existing housing stock is up to code, abandoned buildings are considered for re-purposing and maximize the amount of housing we can provide. CARE Court will help resolve the mental illness element among the homeless. And allowing cities to enforce public camping laws when someone will not accept shelter will help as well.
There are so many contributing factors: substance use, adequate care for mental health, social exclusion, and adverse childhood experiences. I would also argue grief, loss, and bereavement play a role here as well. Getting appropriate care and support to right people at the right time is an incredible challenge and we know these experiences have a cumulative impact in a person's life. For me, the question is: how do we look at the whole person and make available services and support that is appropriate to them?
When working as a patrol officer and encountering the homeless it was often apparent they suffered from mental illness. Many also demonstrated characteristics of alcohol and/or drug addiction. Unfortunately, when I was a patrol officer, there were few, if any, interventions that could be used to help the homeless population. However, I am encouraged to see that more interventions are now available and that streamlining them enables to bring assistance in a timely manner. Yet, there is much work to be done with respect to the government's involvement with mental health services. Not only are these agencies overwhelmed but insurance agencies impose restrictions that often tie the government's hands. For instance, I once had a bank robber who suffered from mental illness and was institutionalized. But when their insurance coverage changed, it limited the resources available to them--specifically how long they could be institutionalized. In this situation, the limit was two weeks. On the day of their release, they left the institution, walked down the street, and robbed a bank. When arrested, they stated the keywords that trigger an evaluation for suicide and were readmitted into the institution. The system became a revolving door.
Thanks for your article Dr. Jay Slosar, Psychologist. Homelessness and mental health go hand in hand. As a reporter covering stories about people experiencing homelessness, I would hear and see first-hand what you talk about in your article. It’s hard not to suffer some form of mental illness when you are on the street, sleep deprived or sleeping with one eye open for fear of robbery or physical assault. San Diego has come up with a way that seems to be making a difference, it’s too bad L.A. can’t do the same to help those in need.
Any human being subjected to living in inhumane conditions like an Animal would cause them to become mentally unstable. I've researched this topic, personally dealt with it, and advocated. Many turned a blind eye stating it's their fault for being homeless. I've written numerous articles on my blog www.consumer2savlives.wordpress.com and even tried to run for Office, and develop programs to help underrepresented human beings. The Fact is no one cares! If it doesn't fit their personal agenda or pocketbook they don't care if the homeless live or die. As well the money isn't getting to the homeless people correctly. Let's add that many women and children are being raped, molested, and trafficked on a nightly basis. Although people act as if they care about these women and children which is BS!!!
In my mind, I’ve been constructing a response to all the news regarding homelessness crisis responses by cities and counties lately. From my perspective, way too much funding is being earmarked for “ homelessness” which is merely a symptom of a much bigger systemic and legislative fix that is being overlooked. Money won’t be able to fix this, it’s the back end result of several policies. Housing is important but because our system is frantically scrambling to find it, build units, we overlook the years lost by not investing in the healthcare, mental health, corrections systems. All three of these systems have been substantially pushed into county control, without funding or infrastructure to manage growing need. meaningful activities like employment, community service, mentoring, vocational training can make for a viable and even sustainable life, in the greatest potential format for each person. In todays system, well since 2015 specifically, the system of care has had to shift from a program of diverse assistance opportunities, to a system that must also mitigate the criminal elements, now fueled by the new pandemic, fentanyl and opiate addictions. More to follow…
This problem is not going away and has been a problem since this country began. As the population grew so did the problem. There are a number of things to consider when addressing those who are experiencing homelessness. Mental health for sure. Substance abuse definitely. In some cases they cooccur. There are those that have been let go from a job or had a life-altering health problem. Still, more are just lost in a vast sea of endless lists and assessments by well-meaning organizations stating that they are there to help, but understaffed, untrained and yes not paid very well. There is a ton of cash being allocated for homelessness, however, not much has changed. Simply housing everyone and then sorting out their various issues is not going to work. Jails aren't working so why would this? Affordable housing would help, but that only works if the housing is located in an area that is affordable. Case management, life skills, coping mechanisms, and time to practice these new concepts while being monitored would be ideal. Of course, there are a number of other issues to consider and none of those have to do with those that are homeless. 1.1 billion is a lot, but not compared to the overall infusion through HUD etc..
I agree. I think the experience in San Francisco shows that. So where to build the permanent supportive housing is the problem. The problem then reflects why we have such a retractable homelessness issue in the first place. That would and should take us to socioeconomic solutions and pathways.
But you hit a major issue as per the rights of homeless and mentally ill persons. California has recently passed a CARE Court Act. Under the CARE Act, families, clinicians, first responders and other authorized adults can petition the civil court to create a CARE health plan for a specific individual suffering from mental illness and order them to follow the plan for up to a year, which can then be extended another 12 months. But just yesterday disability advocates filed a lawsuit against it. Disability advocates file lawsuit against California's CARE Courts system - UPI.com The homeless/ mental illness problem is complex.
We may have some hidden homeless issues among Americans abroad. Here in Japan, it is legal to deny both employment and housing based on age. There is no communication with our Embassy. The current ambassador just held his first town meeting online for American expats in Japan. I know one American woman whose family has depleted savings to get her cancer treatment for years. I ran into her on the street in Yokohama in December on a bitter cold night. I took her out to dinner and gave her cash for inexpensive hotel. Her cell phone was broken… The San Diego model sounds ideal but does it help people to retrain and become employed again? This woman is intelligent but there is an OCD aspect. She might be willing to repatriate. I helped her find social work help in Arizona for her mother, a lawyer who was living in a trailer, is now in a Senior facility and has dementia. These people are former middle class people who have fallen out of the social safety net in both countries! The Australian government is retraining veterans with basic tech skills. Japan has a declining population and is importing Indian IT workers and managers.
Julia It is true that overall, the shelters aren’t working. I think they prove more an economic response in contrast to more permanent housing. Incorporation of empathetic caring resources like pets might prove a welcome and simple resource that might make a difference in connecting with homeless/mentally ill persons. I would like to see any reports on that. The housing issues are the classic problem and see my other comments regarding NIMBY and YIMBY. But you raise the medical issues and level of care whereby “the state” as represented even by caring professionals can mandate someone to take meds or receive care. Per your reference to an appeals board, in California, if you are in a secure placement (jail/locked psych facility and refusing treatment or are non-cooperative, a capacity hearing, which is also called a Riese hearing, can be held to determine whether you can refuse treatment with medications. This capacity hearing is conducted by a hearing officer at the facility where you are receiving treatment or by a judge in court. This can even then authorize staff to give the med by force if necessary.
Overall responding to deaths of despair would also involve homelessness. https://www.statnews.com/2021/12/29/deaths-of-despair-unrecognized-tragedy-working-class-immiseration/
Susanna Marshland Thank you for providing experiential analysis and recommendations. It is so valuable when those who have implemented programs provide feedback. Supportive housing as described in what you sent I like very much. It's just the NIMBY folks don’t want homeless around and so the issue becomes where and how we can provide the supportive housing. It is now countered with a YIMBY group which just released a homelessness report. https://cayimby.org/new-report-highlights-solutions-to-homelessness-crisis/#:~:text=SACRAMENTO%20%E2%80%93%20Today%2C%20California%20YIMBY%20released,solutions%20for%20Californians%20experiencing%20homel The overall affordability of housing is a broad socioeconomic issue and a real problem that to me threatens quality of life and even the success of capitalism. The average price of housing and real estate has dramatically increased and is beyond economic rationale. It begs the dreaded political question of regulation. It used to be that your budget was referenced by the 28% rule which states that you should spend 28% or less of your monthly gross income on your mortgage. Try that today.
On the housing topic, there have been many articles recently about the need for both affordable and supportive housing and the many years of underinvestment in housing in CA (which makes it hard for people of almost all income levels to find housing and thrive), and streamlining the housing development processes could help (see this article from the NYT on the many ways we drive up the cost of "affordable" housing through well-intentioned regulation requiring oversight: https://www.nytimes.com/2022/10/23/opinion/los-angeles-homelessness-affordable-housing.html?auth=login-google1tap&emc=edit_nn_20221023&login=google1tap&nl=the-morning&te=1). I also have seen the research on the effectiveness of supportive housing that Adam Nelson references (see https://www.csh.org/supportive-housing-101/ to read more), and as someone who has developed and operated those programs I can anecdotally report that they work for most individuals with complex care needs -- though not all.
French Parliament recently approved permitting their expat seniors to receive pensions abroad but there have been (related? Unrelated?) demonstrations in France against extending the retirement age. Do we know how many homeless are elderly and without families?? Also, what could be done by public-private partnerships to renovate housing and do training for present and future employment opportunities? Is US DOL collaborating with housing and mental health agencies at state and federal levels?
Providing community centers and addressing immediate needs can prove essential when its done at a local level. I wish schools--high school to college actually required students to get involved.
Adam sorry the link went poof. Try this https://www.latimes.com/homeless-housing/story/2022-11-04/san-diego-homeless-housing-success
It will be interesting to see how CARE COURT does--CA's new plan. I think the Miami model is better. Perhaps we should embrace YIMBY--Yes in my backyard. They have a new homelessness report out. http://cayimby.org/
There are a lot of factors at play. In another writing I have advocated for a forensic mental health hospital modeled after what has been done in Miami.
Ken: I see that ALL the time. In and out of jail. A longer- term placement is needed--a forensic mental health hospital like they have implemented in Miami. https://miamifoundationformentalhealth.org/jail/
Ken, thank you for your service. It is so upsetting the way our politicians and citizens disrespect law enforcement. Police are not the enemy. We need them to protect us and to arrest criminals. The idea that people want to defund the police is disgusting and dangerous. Of course there are those in law enforcement who are not suited for this job and need to be fired. My family has ties with law enforcement and I believe the majority of police are great people trying to do a horribly difficult job. They deserve our respect, not contempt. Vilifying police is disgusting
The classic scene is people walking in the cities and just walking around homeless people on the sidewalk like they aren't there. Efficient government is a factor.
Candance Kudos and praise for all your efforts. I know -- it is cold and callous out there and then with the NIMBY syndrome. But I don't wanna give up--people will care if mental health improves. I wonder --where are the spiritual and church leaders? The Catholic church still advocates for the poor.
You have such in depth experience and perspective on this that I really want to hear more and collaborate with you. Especially with regard to integration of all these areas, That DEFINITIELY is where its at. I certainly agree money is not the answer but always the prototypical American response.