In almost every class I have taken in the social work department, a topic that has come up has been homelessness and mental health. The idea of homelessness still baffles me and raises so many questions. I think the problem with homelessness in the United States is that it is a multi-faceted problem. There is not one issue that we can pinpoint as the source of the problem. There are so many different factors that go into homelessness. The one factor that I feel we really need to hone in on is mental health. The mental health crisis in America has and will continue to be an issue unless we actually work to create and reform a good mental health care system in our country. Too often, people do not get the help that they need, and they end up on the street. The documentary we watched titled Bedlam was a great representation of the connection between mental health and homelessness. I do not remember exactly what the statistic is for people who are homeless and also suffering from a mental illness, but I know that number is way too high. Instead of putting those who suffer from mental illness on the street to fend for themselves, they should be receiving supportive care to help them live a normal life.
Because persons with serious mental illness or substance use disorders tend to have a lot more difficulty getting out of homelessness, they tend to remain homeless for a longer time. Thus, if someone is doing a point-in-time count of unhoused persons, and they are looking at people on the streets and in the emergency shelters, they will find most of the persons they see have mental illness problems and/or substance use problems. However, if you look at al the people who come in contact with homeless services over a year, or you count unhoused persons including persons in transitional shelters and persons staying with friends or family in informal arrangements (sleeping on cots, couches, or in sleeping bags on the floor), you would find that a smaller fraction of those who experience homelessness in a year do so with a mental illness or substance use disorder. The census of persons suffering from homelessness in Springfield, Illinois typical counts about 25% of the persons as having a serious mental illness. Typically, the serious mental illness count is between 70 and 90, and the total count is around 320 to 350. You have to remember that this is a point-in-time count, so it will overrepresent persons who experience chronic homelessness, which means it is over-representing persons with serious mental illness.
I think most people accept that we may have frictional homelessness, where an individual or family is evicted, hasn't a friend or family member with whom they can stay, and so they must use an emergency shelter. However, without a serious addiction or mental illness, most of these people can, with support and help from case workers, social workers, employment services, and housing services, be back in an apartment within a month or two, and then be paying the rent for their apartment with money they earn (or at least paying a substantial share of their monthly rent with their own money) within a few more months. So, if we have a certain number of unhoused persons in our community, but the case records show that everyone who shows up in an emergency shelter is housed within eight weeks, then I think that would be a situation that we would call a “functional end of homelessness” and an end of chronic homelessness.
I think the documentary Bedlam showed that there are not a sufficient supply of mental health professionals, mental health day clinics, mental health oriented supportive housing, or residential facilities catering to persons with serious mental illness. The documentary also showed there is an insufficient supply of affordable or subsidized studio apartments where persons suffering from chronic health and mental health problems could stay, whether they are able to pay the rent or not.
Another problem with homeless people who have psychiatric problems is incarceration. Too often, those experiencing a mental health crisis will be thrown into a prison without getting the adequate help they need to improve their mental situation. They are not given proper care and their behavior does not change because of this. Putting a mentally ill person in prison instead of a mental hospital is only hurting them. I feel like the culture and taboo around the idea of mental health is improving, but only for certain diagnosis’. For example, I feel as if the discussion around depression and anxiety has been more normalized, but the “heavier” diagnosis’ such as BPD and schizophrenia still have an overwhelmingly negative stigma around them. In reality, people living with these kinds of psychiatric disorders are the ones who need the most support in our world. I cannot imagine how truly terrifying it must be to live in a delusional reality that is not real to anyone besides yourself. That must be the most isolating feeling someone can experience.
In a given year, maybe 6% of people will have some serious symptoms of a depressive disorder, and maybe 10% will be dealing with an addiction. If we include the immediate families of all these people, I'm sure we're looking at about a quarter of the population either experiencing depression or addiction directly or through a close family member or intimate friend. That's about 85 million Americans with experiences with those sorts of problems. With psychotic disorders, we might have 0.3% to 0.4% experiencing schizophrenia or something related to it, and maybe 1% of the population lives with someone suffering from such a disorder. So, that's about 4 to 5 million Americans either living with a psychotic disorder or having a close family member or intimate friend who is dealing with a psychotic disorder.
We have room in our prisons and jails for a couple million incarcerated persons. There are about a million persons with psychotic disorders. With medication and family and public support, probably 600,000 to 700,000 of those persons with psychotic disorders can live fairly independently and have nearly normal lives, with friends and family visiting them. They may need to live modestly, as most of them will not be able to hold employment, but they won’t need to live in a state hospital or a locked mental health facility, and they certainly would not need to be incarcerated. However, I think about 400,000 to 300,000 persons with psychotic disorders probably are not responding well to medications, or they do not have social supports and families who have the time and money resources to take care of them. We certainly have not made it a priority to help these hundreds of thousands of persons get into safe and secure long-term living facilities where they would receive the support they need to live safely. Tens of thousands of these people will end up incarcerated, and it seems to me that over half of them are living in desperation on the streets and in emergency shelters.
In an ideal world, we would have a mental healthcare system setup that is universal and effective. Everyone in the United States needs access to mental healthcare whether that is in person or online through telehealth. If we could provide services free of charge for everyone, I feel as if a lot of lives could be saved/improved. It also needs to be able to provide services such as everyday therapy to drug rehabilitation. Having a wide array of services means that the system would need to have all kinds of professionals on teams to work with people. I also feel as if we should do regular screenings for mental health and certain conditions and start these very early on in life. When intervention can happen early in life, the disease can be managed, and this will improve the person's life as they continue on into adulthood. We also need to be able to provide good hospital spaces and halfway houses for those who need more attention than others. Some people cannot live through their lives by themselves if they have a very serious diagnosis. We need to be able to provide safe spaces for people so they do not end up on the streets. The last place someone with schizophrenia should be is homeless on the street. Overall, I feel like the general attitude towards mental health and mental health crises needs to change. There are so many people who still do not really believe in mental health, my own father is included in this. To be able to move forward as a society and continue research, people need to have an open mind that mental health crises are very real and can be harmful if they are left untreated. While I do feel like we are making some progress, we still have a long way to go before we can formulate a good mental healthcare system that works for everyone, especially the most unfortunate of our population.
I believe the costs of regular screening of everyone aged 18 to 30 for prodromal symptoms of schizophrenia and then providing intensive cognitive therapy to everyone who seems to be developing the prodromal symptoms would be expensive, but would prevent so many fully developed cases of schizophrenia that the net costs would be less than the current situation where we allow schizophrenia to develop, even though we have methods that can usually prevent it. Likewise, we are clearly putting too little investment in the sort of psychological and social training that would prevent addictions. And, obviously, we are not investing sufficiently in treatment for addictions and mental illness. A city such as Springfield with about 110,000 inhabitants ought to have fewer than 1,000 persons with schizophrenia (probably slightly fewer than 500 persons with schizophrenia). With about ten full-time caseworkers we could do a lot for the 200 to 300 of those persons who would need lots of supports and help with securing and maintaining themselves in safe and dignity-enhancing housing. Salaries and benefits and administrative support for about 10 full-time mental health professionals would be less than $1.5 million. It seems to me that for every 100,000 persons in a county or city, the county boards or city councils out to budget about $2 million for local mental health services (to supplement state and federal and public health and private mental health care). The expense of $2 million per 100,000 residents ought to just be a normal budget item for local governments, just like the expense of providing 2.4 sworn police officers for every 1000 residents, or a certain standard amount for libraries, fire protection, and public works.
I also think local governments ought to create parastatal (private non-profit organizations that are governed by rules established by the elected government and with directors who are appointed by elected officials) housing development corporations that would work with planning and economic development offices at the city our county level to regularly increase the supply of social housing. That is, the government ought to set up some non-profit housing corporations that build new housing or renovate and improve existing housing so that there is an ever-increasing supply of non-profit housing available in the local housing market. When bonds or mortgages are being paid off, as no profit is being taken, the rents in such housing would typically be 5% to 10% lower in cost than in the private sector. Once mortgages or bonds are paid off, so that the only need for rent is to pay into escrow for maintaining the physical structures, paying for insurance, and paying property taxes, the costs of rent on such non-profit properties would drop to about 30% to 40% below private market rental rates. Once 20% to 30% of rental housing in a community was being run by the non-profit housing corporation, private sector rents would also decline steeply because of competition for residents. Even in Springfield, Illinois, where housing costs relative to median incomes are some of the most affordable in the nation, this sort of non-profit housing development corporation is needed so we can increase our supply of affordable housing by about 1,000 units. In unaffordable places like the major cities of the west coast or the northeast, such housing development corporations are absolutely necessary, and it's shocking to me that allegedly progressive or liberal city administrations in those cities are not creating such entities or funding them sufficiently to have them significantly increase the supply of public housing. There are models people could examine to see how this can work: Singapore, Hong Kong, Vienna, The Netherlands, Denmark, etc.
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