Where can the unhoused seriously mentally ill, co-occurring, or addicted populations go and what occurs once they are there? For many communities, dealing with a lack of data and accountability, this question is simply unanswerable.
That is why Heart Forward LA hosted a CORO fellow for four weeks to evaluate the current state of the board and care system in Los Angeles County and beyond.
As communities realize the need for more clinically and therapeutically oriented residences for the unhoused with SMI, along with co-occurring and SUD, the Housing First approach is becoming less and less attractive. California experienced a loss of more than 32,000 beds in state mental health hospitals from 1960 to 1985. Community-based adult residential facilities emerged to house those that needed care. These facilities, however, have failed to garner enough state support leading to their decline and the loss of beds for those that need them.
Through support from Coro Southern California and Heart Forward, a new review of housing for the SMI subpopulation in adult residential facilities (ARFs) illustrates the tremendous gap in information about these valuable community resources. The report seeks to understand this critical type of housing and why they are disappearing.
To remedy this significant problem, Wisner recommends the funding of new research to understand the specific conditions of the ARF industry and how it serves those residing in ARFs. Wisner’s recommendation of an immediate funding patch to keep existing ARFs operating is combined with the serious need for research to create a sustainable, system of Housing that Heals emphasizing quality and therapeutic outcomes.
Hope Street Coalition participated as a member of the Heart Forward ARF Research Advisory Panel to guide the direction of No Time to Waste. The better we understand the existing residential structures and support systems that often fail those with a serious mental illness in our communities – housed and unhoused – the better we are able to create appropriate interventions.
Many people are left living on the streets because they need so much more than a subsidized place to live from the Coordinated Entry System. They cannot navigate a lease or get to needed treatment appointments. They need a community where this is provided in what mirrors a campus.
No Time to Waste is the necessary alarm pointing out the silent crisis that exists in counties throughout California. Given how mental health policy and coordination has been delegated to counties, it underscores that unintended consequence of the state relinquishing authority to this domain. It documents how lack of data results in disinvestment, unknown quality, and the destruction of needed community assets. Without sufficient residential treatment facilities to provide homelike clinical care for people living with serious mental illness in our communities as well as the co-occurring or addicted populations, unsheltered homelessness and human suffering will increase.
Policy makers, think tanks, government agencies, and foundations should take up Wisner’s call and start doing the work of understanding the state of ARFs, who they serve and how they serve them, and what needs to be done to improve these facilities and the systems of which they are a part. To continue the status quo and see these valuable community assets disappear harms people and harms communities.
The Biden administration, through the U.S. Department of Housing and Urban Development (HUD), has unveiled its latest strategy to solve homelessness. Its first initiative on homelessness, House America, is perhaps the weakest and most status quo repackaging of the very policies that have led our country and communities to daily witness unbelievable suffering on the street.
Through House America, HUD and the United States Interagency Council on Homelessness (USICH) ignore the serious challenges of solving homelessness. Housing America continues the sole provision of housing despite the overwhelming need to address the mental-illness and behavioral-health crisis plaguing the streets of American cities.
House America simply directs American Rescue Plan dollars to the creation of affordable housing and, poof, homelessness will be solved! Why didn’t we think of that before? The reality is, we have.
This is the same housing-centric strategy that has been in place for more than ten years, with the same unrealistic goals and denial of root causes of homelessness. HUD and USICH think it’s a big deal to offer HUD advisers and industry consultants to communities when it’s been available all along. In fact, technical assistance to communities for homelessness enjoys a separate congressional appropriation of $5 million a year.
The goals of the Biden homelessness team are to remove from the streets no fewer than 100,0000 people experiencing homelessness and to start the development process of 20,000 new units of affordable housing by next year. Here is a tip: To achieve these goals, avoid California. Los Angeles has been working to develop 10,000 units since 2017, with little to show for it but delays, cost overruns, waste, and heartache. According to the website Local Housing Solutions, “as of August 2020, 179 supportive units have been built with HHH funds and another 5,522 are under construction or in pre-development.”
Biden’s plan is laughable on its face. It’s pandering to the National Alliance to End Homelessness, the National Low Income Housing Coalition, and other Housing First ideologues who are in denial about the crisis of the untreated and unhoused mentally ill and drug-addicted. These special interests have exacerbated destitution, morbidity, and mortality by requiring communities to substitute “services” and housing for treatment and clinical interventions.
Instead of repackaging the same old PR about housing as the panacea to homelessness, the administration should get real with the unfettered pathologies on display on Philadelphia’s Kensington Avenue, in San Francisco’s Tenderloin, and in Los Angeles’ Skid Row. Address the fact that Medicaid’s Institute of Mental Diseases exclusion places a cap on reimbursements for state psychiatric beds and capacity, causing a shortage of treatment beds. Deal with Substance Abuse and Mental Health Administration’s (SAMHSA) funding of disability-rights groups that would rather the mentally ill “die on the streets with their rights fully intact” than receive treatment. And give communities the flexibility to choose high-barrier homelessness-assistance approaches that show results in moving people from the streets and into sobriety, employment, and self-sufficiency.
The last five years of Point-in-Time counts reveal that homelessness — particularly chronic homelessness — has increased. Awards to communities have increased 27 percent to more than $12 billion in HUD Continuum of Care awards alone over the last five years, while chronic homelessness has increased by 25 percent. This increase has occurred while the Obama, Trump, and now Biden administrations have emphasized a housing-centric approach toward homelessness. Now with the flood of billions of dollars in CARES Act and American Rescue Plan funding, the feds are providing nothing new but a PR opportunity for mayors and others to preen about housing and homelessness.
House America keeps the weak sauce flowing. Instead of understanding the costly and deadly intersection of homelessness, mental illness, and addiction, the Biden administration continues to whistle past the outdoor asylums and drug encampments to marvel at what could be if we built more affordable housing.
With daily deaths occurring among the homeless — five a day in Los Angeles and three a day in San Francisco — we need to get serious about what’s happening in our communities that is far from whether or not people can afford the rent. It’s past time to recognize the devastation that is occurring to the vulnerable and ill and to the communities in which their pathologies play out.
Paul Webster is former senior policy adviser on homelessness at the U.S. Department of Housing and Urban Development. He is the founder and director of Hope Street Coalition, an advocacy organization focusing on policy reform at the intersection of homelessness, mental illness, and addiction.
[PW1]HHH is a city-wide bond obligation of $1.2 billion in L.A. to create 10,000 units.
Hope Street Coalition has submitted an amicus (friend of the court) brief to the 9th Circuit Court of Appeals in the L.A. Alliance v City and County of Los Angeles case. This is the case where Judge David O. Carter has ordered the City and County of Los Angeles to come up with a way to shelter the unhoused of Skid Row. Los Angeles City and County have appealed this order to the 9th Circuit Court. This case has the entire homelessness industry watching and, depending on how the Court rules, could be a significant game changer.
Judge Carter issued an injunction ordering the City of Los Angeles to escrow $1 billion to shelter those on Skid Row. Many, including Andy Bales of Union Rescue Mission, thought Carter’s order is the right move to push back against the entrenched interests leaving people to suffer and die on Los Angeles’ streets.
A few weeks ago, Andy asked me to submit an amicus brief that would support Judge Carter’s order. I worked with a wonderful law firm and we focused on the need to address the lack of mental health treatment for those on the streets. Judge Carter ordered LA County to audit the number of mental health and addiction treatment beds in the county. He also ordered the creation of 1,508 sub acute treatment beds for the unhoused mentally ill and addicted. Hope Street’s brief supports those actions.
The Hope Street brief makes these important points:
Hope Street supports the District Court’s Order because it demands immediate action and accountability from the City and County of Los Angeles to provide shelter and treatment of the mentally ill and addicted on Skid Row.
By focusing on providing permanent supportive housing as a sole means of reducing homelessness, the unhoused homeless suffering from mental illness and addiction have been dying and suffering on a massive scale. Judge Carter’s order will be an important first step to changing the status quo.
Permanent supportive housing cannot provide the positive clinical outcomes for those that make up the majority of those experiencing homelessness—the mentally ill and addicted. Due to the lack of investment, and the regulations of federal and state funds to address homelessness, the population that makes up the largest share of the unhoused will continue to be underserved, unless the City and County are required to meet their treatment needs.
It’s a miracle I’m alive today. Addiction caused me to go from middle-class county worker with a family, mortgage, and little league obligations to street addict hustling for the next fix. My experience resembles millions of others, revealing a dark and desperate climate where it is far too easy to get high and extremely difficult to get sober.
Just a few years ago, I was addicted to heroin and living on the streets of the Tenderloin, San Francisco’s most notorious drug and homeless district. The effort underway to recall District Attorney Chesa Boudin is due, at least in part, to his abject failure to grasp the aspects of addition and, in turn, his inability to address his city’s humanitarian crisis.
Illicit fentanyl hit San Francisco in 2018, and related overdose deaths immediately spiked. From 259 that year to 713 in 2020, the city is on pace to notch 1,000 deaths in 2021. This death toll exceeds that from COVID-19. The sharp assault on one’s senses of masses of addicts sprawled out destitute, impoverished, and comatose in their own filth should elicit mercy and support. Yet there’s no urgent response.
As of today, the San Francisco Department of Public Health sanctions only 35 detox beds for its population of 800,000, where at least 25,000 are identified with substance abuse disorder. These 35 beds are a small part of the 486 total treatment beds available for detox, residential treatment, and step-down programs.
Not only are detox beds scarce, but the process to gain access to them is extremely difficult. The San Francisco Department of Public Health’s Access Center ostensibly helps addicts, but keeps banker’s hours and is akin to the DMV. Bureaucracy and week-long waitlists there are the norm. And addicts aren’t exactly “motivated consumers” with the patience to see it through.
There still is a quick and easy way to get treatment—sometimes. An addict has to commit a crime and end up in jail. Police can fast track addicts into a variety of private or state-funded drug treatment programs within several days, but the addicts must act on the offer for treatment quickly before being released. In effect, law enforcement and the addict have to work against the system before the District Attorney gets involved.
San Francisco has drug courts whose function is to mandate people to drug treatment as a jail alternative. While the District Attorney publicly advocates for their expansion, he undermines that pledge by actively speeding the release of addicts before they get to the courts. This has caused a sharp decline in arrests for open drug use.
If the sole purpose of decriminalizing drug use is fewer arrests, it’s working. From February to April, the San Francisco Police Department’s Tenderloin Station made 60 arrests per month for drug dealing. In those same three months, the police only made three arrests for drug possession and issued one citation for drug use. Drug dealers are being released from custody by the District Attorney as fast as they’re being arrested.
In short, San Francisco’s “restorative justice” model means no addict is getting arrested, going to jail to get clean, being mandated to drug court, or being put on probation.
San Francisco is trying to address its addiction crisis with more street outreach, safe sleeping sites, and street-crisis response. However, these efforts often result in addicts remaining on the streets because volunteers and outreach workers have nowhere to refer drug abusers for treatment.
San Francisco needs more beds and, critically, lower barriers to treatment. This must be paired with a massive public outreach effort to motivate the addicted to get off the streets and seek help.
Further, the city needs mobile vans with identification and health-system access to transport overdose victims to detox. Rehab pods should be added to county jail to introduce recovery during even short stays in custody. Further, Medically Assisted Treatment (MAT), which is the use of prescription medication to treat substance addiction such as opioid abuse, needs to be available to addicts while in custody to initiate a fast track to rehab.
This response is appropriate given the incalculable number of lifeless bodies strewn across sidewalks and in alleyways. Unfortunately, it has been met with resistance from officials like Chesa Boudin, seeking to avoid the perception of an increased criminal justice element.
Forget politics. We can no longer minimize addiction’s role in the vast increase in homelessness and loss of life. Drastic measures to alleviate the suffering in our American streets must be taken, otherwise, the stream of senseless deaths will continue forever.
Thomas Wolf is a former homeless heroin addict who advocates for recovery and treatment programs. He provides tours of the Tenderloin District of San Francisco to raise awareness of the devastation of drug use. Tom can be reached at 650-822-3107 or at firstname.lastname@example.org
In his State of the City address, Mayor Eric Garcetti announced the dedication of $1 billion to address homelessness in Los Angeles. The funding will go toward encampment clean-up, rental assistance, legal services, and the creation of affordable housing.
Under the Mayor’s plans, people will get housed, but the streets will remain the dystopian and destitute outdoor asylums that harm people and communities.
Why so skeptical? To start, funding and capacity for homelessness assistance has increased every year since 2009. More permanent supportive housing, rapid rehousing, and bridge housing are available than ever before to house roughly 66,000 people experiencing homelessness in L.A.
Yet, homelessness continues to grow. Over the last five years, homelessness in L.A. has increased 55 percent and chronic homelessness has risen by 73 percent. During this period, L.A. spent more than $2.5 billion in federal, state, and local revenue for homelessness.
Two significant gaps exist that keep people on the streets. The first is the reality that the less vulnerable are easier to house. Those without mental illnesses and/or addictions are more able to respond to assistance and stay in housing than those that inhabit encampments. Current homelessness programs have become nothing more than temporary holding beds for the recently homeless waiting to compete for affordable apartments. The unhoused seriously mentally ill and addicted will continue to refuse housing and services because they are too sick to understand the offers and escape the streets. Mental illnesses and addictions reduce cognitive function and often result in symptoms that produce paranoia and fear.
People with very low incomes living on the streets, in cars, or tents for short periods of time do not make up the bulk of those suffering on the streets. According to UCLA’s PolicyLab, the mentally ill and the addicted make up most of the unsheltered homeless. In their survey of more than 6,000 people living on the streets, 78 percent reported mental health conditions and 75 percent reported substance abuse.
The second significant gap is the unavailability of treatment for those suffering from serious mental illness and/or addiction. With fewer than 6,000 public psychiatric beds in California, and an estimate between 32,000 to 48,000 unhoused mentally ill and addicted in Los Angeles, it’s easy to understand that the streets are the dumping grounds for our most marginalized citizens.
The barriers to and lack of psychiatric capacity and addiction treatment results in a cycle of jail, emergency departments, and encampments until prison, suicide, or death remove the unhoused mentally ill and addicted from the streets only to be replaced by a continuous flow of new victims. Because homelessness is considered a housing issue, the suffering on the streets will continue to increase, resulting in decompensation and depravity borne by individuals and communities. More people will die and suffer in psychosis and filth while the Mayor provides rental assistance, hotel and motel vouchers, and the hope of new permanent supportive housing units.
More resources directed at the humanitarian crisis of our time is a good thing. Existing programs and funding, however, focused on housing instead of healing have failed to move the statistical needle in the right direction. More funding, without supportive treatment programs and house for the mentally ill and addicted, will change nothing.
Recently I was following a conversation on the app ‘Next Door’ about homelessness. The participants were complaining that tents, RVs and individuals seem to have taken root in the community, like where the old Burlington Coat Factory used to be.
A City Councilmember chimed in saying every person experiencing homelessness in the city has been offered shelter and services. He suggested that nothing more could be done to clean up the community or about those living unsheltered.
My mind recalled the countless conversations I’ve had with the family members of the mentally ill. They’ve told me about restraining orders, searches in back alleys and shelters for their child, and arguments with law enforcement over illnesses that cause odd and threatening behavior. These family members wished there was some way to compel their loved ones into treatment but arcane laws and antiquated rules tie the hands of law enforcement and public health systems. Dr. Drew Pinsky talks about how absurd the current situation is here.
In California, the fifty-four old Lanterman-Petris-Short Act (LPS) governs conservatorship – the appointment by a judge of a guardian or protector to manage the daily life of another due to mental limitations. According to El Dorado County District Attorney Vern Pierson, LPS all but ended the practice of institutionalizing patients against their will. LPS was a product of its time and based on outdated scientific/medical information. We now understand that these are brain diseases and that 50% of those with psychosis cannot recognize they are sick due to cognitive impairment. In the first year after LPS was enacted, the number of mentally ill people entering the criminal justice system doubled.
Now, a new report by Alex V. Barnard of New York University, demonstrates that California’s conservatorship law is creating incentives to hospitals, mental health professionals, and law enforcement to use the streets as the dumping grounds of California’s mentally ill.
According to Barnard, communities are electing to put fewer people into long-term conservatorships and, instead, are using more short-term ‘holds.’ The maze of regulations necessary to conserve someone is so great, and the funding and staffing necessary to conserve is so expensive, public entities resort to superficial and inconsistent decisions. Decision making is not clear, standards are ever-changing, and a lack of placements creates a sense of futility where the street becomes the easiest solution.
“Police see people who are high, and a
5150 is an easy way to get them off the
street. The ER won’t admit them, and
they come back. The system is kind of
– County MH Director
According to the Hospital Association of Southern California, it’s estimated that approximately 1,000 individuals are on a 5150 hold in an emergency department on any given day. California hospitals see more than 1 million individuals with a behavioral health diagnosis in their emergency departments annually. In addition to the high threshold for conservatorships, the scarcity of psychiatric beds creates a “no room at the inn” scenario for those suffering with mental illness.
The lack of facilities, funding, and the complexity of the way to help those suffering on the street has created conversations about whether people are “successfully homeless.” Barnard quotes one County Public Guardian saying, “We’ve had clients who are homeless by choice…You or I may not feel that’s good for them, medical health wise or mental health wise, but it’s their choice, and if they can articulate that, ‘I go to the soup kitchen, I go to Goodwill, I have Social Security, and I use that income to buy those clothes, and I have a sleeping bag, that’s what I want,’ well, the doctor may not feel that’s appropriate, but if they’re able to articulate that…we may reject that referral.”
The Councilmember cited previously may identify with the Public Guardian – that there is little we can do. But that ends up as a system of managing suffering and destitution instead of solving and treating the needs of the unhoused mentally ill.
The truth is that LPS is overdue to be reformed or replaced. This antiquated and ineffective law has directly caused untold deaths, human suffering, and community destruction. What’s needed is for those complaining on Next Door to contact their state legislators and help them connect the dots that thin mental health services and out-of-date laws are contributing to the destruction of communities and the decompensation of people living exposed and vulnerable.
Since the 1950s, the large majority of mental health hospitals across the country have been closed, resulting in a dramatic decrease of psychiatric beds providing treatment to the seriously mentally ill. As a result, prisons, jails, and the streets have seen a significant increase in mentally ill residents.
More than 170,000 people with mental illness experience homelessness nationally. According to the Treatment Advocacy Center, in 44 states, a jail or prison holds more mentally ill individuals than the largest remaining state psychiatric hospital.
Kerry Morrison, of Heart Forward, recently posted an excellent explanation of how the IMD Exclusion has a direct effect on homelessness. With her permission, I’ve copied it here from her blog Accoglienza.
How the IMD Exclusion Connects to Our Homeless Crisis
Driving east on Hollywood Blvd two days ago, as my car was stopped at Vine, there was a young man hugging the wayfinding sign. He was barefoot and clothed only in plaid flannel pajama bottoms. His hair and beard, though not groomed, did not look particularly unkempt which made me think he had recently wandered away from some place.
My first thought was that there was a mother somewhere who was worried about him. A mother who was likely feeling helpless in her inability to prevent her son from ending up barefoot and half naked at the corner of Hollywood and Vine.
I am currently reading the book Tomorrow Was Yesterday, compiled by Dede Ranahan. It’s hard to read; I can only take a few pages at a time without feeling enormously sad. More than 60 stories are shared by mothers who have faced grief, loss, frustration, pain and tragedy as their sons and daughters confronted the American mental health system. None of the stories, so far, have a happy ending.
That young man at the corner of Hollywood and Vine is not experiencing homelessness. He is experiencing something far more tragic and ultimately life-threatening.
The elephant under the rug is the lack of sustained and recovery-oriented inpatient treatment for people living with severe mental illness in our communities – all across America.
How people find their way to living on the street, in a tent, or in their car is complicated. Yes, housing costs are rising and wages are not keeping pace and the pandemic has exacerbated an already troubling situation in Los Angeles.
But there is a significant percentage of people experiencing homelessness, who have battled mental illness, or substance abuse, or both, who need attention above and beyond a room key. How many? One in four, is the conservative number as reported by LAHSA using the federal HUD definition.
The young man hugging the wayfinding sign will not start his recovery journey in a shelter, or bridge housing or in his own apartment. Maybe later; but not now.
I so appreciate the people who read this blog and ask: “how can I help?”
Here is something you can do. We have to shift the narrative away from the response that housing is the singular solution to homelessness and turn up the heat on the need for sustained and effective inpatient treatment for mental illness and substance use disorder.
Let’s put on our fifth grade hat to understand the “IMD Exclusion”
Truth be told, researching and writing this blog has helped me collect my thoughts on a federal policy that is very confusing but incredibly impactful as it relates to our homeless crisis. My goal is to make this accessible to lay people – so that you, and me – can keep asking the question: “do we have enough psychiatric treatment beds to meet the needs in our community?”
The answer is no. Here is one extremely detailed report from the L.A. County Department of Mental Health that attests to this.
Here is one solution. We need to ask our county, state and federal policymakers to eliminate the IMD Exclusion.
Ugh. What the heck is that? It sounds like a variant to the coronavirus. How can I ask for something I don’t even understand?
One reason relates to the federal government’s policy that Medicaid (insurance for very low-income people) cannot be used to pay the expenses of someone living in a treatment facility that has more than 16 beds. These are referred to as Institutes for Mental Disease (IMD). The >16 facility would be “an institution” although it’s hard to understand why 16 is the magic number.
How did we get here?
There was great hope in the 1960’s after President Kennedy signed into law the Community Mental Health Act. The hope was to shift resources from large institutions into community-based treatment. This movement was not limited to the U.S. As I have written about extensively in this blog, this was happening in Italy as well, and Trieste represents the “north star” in looking at how the commitment to community-based support truly led to a qualitative improvement in the quality of life for their neighbors living with a mental illness.
During that decade alone, over 165,000 people were discharged from psychiatric institutions, but the community-based resources did not materialize in such a way as to absorb this influx. (See American Psychosis, an excellent reference book, page 71.)
How this shift from the federal to state and local governments was going to be funded was at issue (and still is, to be frank).
One development during that decade that has had far-reaching consequences was the change to the Social Security Act.
Under President Johnson, Medicare and Medicaid were created as part of a revision to the Act. Medicare provides hospital insurance for people 65+ and is funded by the federal government. The intent of Medicaid was to pay for medical care for poor people and is funded by a combination of the federal and state governments. Neither was intended to serve as a funding source for mentally ill people. The expectation was that the states would provide care for their mentally ill residents.
However, because states were caring for so many people in their state hospitals, the federal government wanted to make sure that the financial burden would remain with the states.
To protect against this this, the Medicaid rules stipulated that funds could not be used for people in mental institutions. This became the Institutions for Mental Disease (IMD) exclusion. Somehow, they arrived at the threshold of 16 beds constituting an institution.
There seems to be a growing awareness that repealing the IMD Exclusion, or making it easier for states to secure a waiver, is a policy worth pursuing to provide a higher level of care for people living with a mental illness in our country. In this blog, I am raising this issue to equip my readers to learn more, and engage policy makers in discussion. This is how we pursue change.
So, arm yourself with this knowledge. Keep asking the questions. Impress upon our policy makers that our humanitarian crisis of homelessness is far more complicated than a shortage of affordable housing. Stay tuned to this space.