Free Writing Exercise with student considering housing and mental health policies

 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.  

Some student reflections on SNAP

  SNAP has always been something that’s controversial, in my mind.  Growing up I would hear and see people talking about others being poor in the grocery line, not knowing the context or implications that those words may have.  To the people it was directed it, they would get uncomfortable—which of course I understood at the time—but the real world implications of this happening everywhere is quite telling. 

Now the government provides EBT cards that look like credit or debit cards to help with some of the social stigma surrounding SNAP, allowing users to buy groceries without the judgment that they used to experience.  It’s not just the fact that these judgments happened, it’s the fact that people can look down on others for being poor or experiencing temporary hardships, which we all have in life.  I don’t understand why we need to constantly judge others for their situations; instead we should be kind and offer help where needed.

No, this doesn’t mean going up to every SNAP family and asking if they need help.  That would be silly and add to some of the social stigma; instead, gaining real world experience by volunteering at shelters or local programs that help the poor.  Understanding where these people are coming from, and recognizing that not everyone is the same.  Not everyone is abusing the system and driving Mercedes home.  There are people out there trying to get by and to be judged for that is immoral, in my mind.

Hopefully this paper isn’t controversial for those currently in Social Work or going through school to become one.  I don’t want to confuse anyone reading this, however—people can judge others for anything, but to vocalize it and put others down is wrong.  Therapists can judge clients, but they should never vocalize those judgments in a negative way.  

Emotions aside and judgment aside, I want to move towards the benefits and downfalls of SNAP in general.  The program is wonderful, but it has shortcomings as do most things that are government ran (some would argue all things).  One of those things is not accounting for specific circumstances per family.  What I mean by that is certain areas have higher costs of living than others.  So if a family lives in Washington DC, it’s probably going to be more expensive than a family that lives in Memphis, TN.  The government should focus more on cost of living areas rather than a static number based on how big a family is.

One of the great things about SNAP is how it allows families food security while letting them spend money that would have otherwise gone towards food to go to other important things, like rent or utility payments.  Having food security makes a world of difference when you’ve experience insecurity yourself.  It helps with depression; health outcomes; academic outcomes; life expectancy.  All of these things because of one single government program.

I have a friend that uses the program and she benefits tremendously because of it in her life.  She would say all the time that she wishes she didn’t have to always eat ramen noodles because she’s worried about the long term health effects of doing so.  When you get older, thinks like nutrition start to  matter a whole lot more than to a 19 year old collect student in a dorm room forced to eat the same thing for a couple of semesters.

Nutrition is very important.  Unfortunately, SNAP doesn’t necessarily accommodate the highest efficacy in nutritional returns, but some would say its good enough.  I’m in a similar mindset—as long as some nutritional goals are being met and ramen noodles aren’t being served for breakfast, lunch and dinner everyday, then clearly it’s a net benefit to be in the program.

An academic journal talking about poverty in America and how SNAP helps alleviate it had this to say: “We found an average decline of 4.4 percent in the prevalence of poverty due to SNAP benefits, while the average decline in the depth and severity of poverty was 10.3 and 13.2 percent, respectively. SNAP benefits had a particularly strong effect on child poverty, reducing its depth by an average of 15.5 percent and its severity by an average of 21.3 percent from 2000 to 2009.”

References:

Smith, J. A., & Doe, R. B. (2017). Alleviating poverty in the United States: The critical role of SNAP benefits. Economic Research Service, U.S. Department of Agriculture. https://ageconsearch.umn.edu/record/262233/files/17742_err132_1_.pdf 

You mentioned that Not everyone is abusing the system and driving Mercedes home.  That is an important observation, as it seems to me that many people quickly raise the issue of cheaters who use SNAP benefits because they falsely report low incomes, or who have low incomes, but have hidden wealth or support. I think anyone who deals with the general public soon realizes that a small fraction of people (probably fewer than 5%) are sort of dishonest, slimy, predatory, or psychopathic.  In any system involving lots of people, there are going to be a fraction of people who cheat, steal, lie, and justify this behavior to themselves. However, the sort of cheating where people with hidden wealth or unreported incomes use SNAP must be extremely low (estimates from 2018 suggested a 0.14% fraud rate where recipients were investigated and found guilty of fraud.  If that is 20% of all recipient fraud, the actual level of fraud might be as high as 0.7%.  Fraud committed by retailers trafficking SNAP benefits is estimated at about 1%). 

Your citation from the 2017 article is also encouraging, as it suggests that SNAP makes a significant reduction in experienced (post-tax / post-benefit) poverty. 
I wonder sometimes whether it might be better to just give poor people cash rather than SNAP.  SNAP benefits can only be used to purchase uncooked food (although there are grocery stores that will cook some raw foods for you as a service, for no fee), and so while SNAP benefits help make malnourishment and starvation exceedingly rare in our society, the problems of housing insecurity or other problems of poverty cannot be addressed so much with SNAP, aside from the point you make that every dollar in SNAP is a dollar less the family needs to spend on food, giving the household more money to use for other necessities.

I'm a bit concerned about refusing to allow households to spend SNAP benefits on sweetened drinks, candy, or other morally suspect foods.  A goal of a welfare safety net is to give freedom and autonomy to persons who are suffering a period of low income, either because of an economic hardship they are temporarily passing through, or some more permanent problem, often related to physical or mental health conditions or disabilities. Restricting what people purchase with SNAP benefits will be justified by health concerns, which is why a person is not allowed to purchase cigarettes or alcohol with SNAP benefits, but at some point the restrictions on SNAP use cross from nutrition and science to moral or religious reasons, and I’m wary of that.  For example, I suspect that consuming most meat or animal-derived food products available in supermarkets is immoral, since much of that meat is generated through industrial livestock systems or industrialized marine harvesting, and so if we are going to forbid the consumption of alcohol or soda pop, why not also ban the purchase of animal-protein products and restrict SNAP users to vegetarian diets?  What if some persons thinks that only organic food is moral or healthy, and we start forcing SNAP to be used only for organic products?  This seems like a Reductio ad absurdum argument, but I think the assumption that we should be strict in limiting what welfare recipients do with the aid we give them is one that we must treat with caution and concern, if we highly value individual liberty and dignity.

The earlier part of your reaction where you think about how people are eager to judge others reminds me of some psychological experiments that show humans tend to be very good at detecting cheating and unfair exchanges where someone else gets an advantage.  Helping people overcome that innate tendency toward distrust, cynicism, paranoia, and judgmental prejudices is certainly a huge task we have in advancing civilization and improving society. I wish people were better at recognizing the actual levels of threat from cheating and deceit. 

As for government programs being inherently inferior.  Of course they are.  In an ideal or perfect society, people would be so honest, charitable, fair, and open-hearted that we would not need a public welfare system, nor police, courts, nor jails.  Taxes would be very low, paying mainly for infrastructural improvements and pooling risk.  Given the scope of the problems we face, given the actual material (humans and their human natures) we are dealing with, we must settle for government and coercive charity through social welfare systems, at least for the time being. I look forward to the utopian anarchy our remote descendants may someday enjoy when people are better than they are now.  

Persons with mental illness are brave

Reaction Paper 2

The video of Elyn Saks from youtube.com that we viewed in class caught my attention and I had many thoughts and feelings regarding the video. So much so that I went home and shared the video with my fiancé. We discussed the video in depth and he shared new insights with me. Watching a woman who is so successful and yet a woman who suffers from a mental illness that many would fall broken to. Her strength is grand and inspiring to watch, her story needing to be heard. 

The idea that a person with a mental illness cannot succeed professionally or in any aspect of their lives is obscene and unneeded. Did she struggle when the illness was at its worst? Yes, of course she did, but she rose above with the help of psychotherapy. The ideas of those she spoke with, regarding mentally ill persons reflects the views of many of the population. Many believe that those who suffer with mental illness don’t mind being strapped down, but those restraints are often uncalled for, and the persons with mental illness are still humans. She pointed admitted how she isn’t so different from those people being strapped down to control them because she suffers as well, but in the  eyes of people who don’t know about her mental illness, it seems she could not be anything like those who suffer mental illness; her higher education and status in society makes it seem impossible that she too could suffer from a chronic and severe condition. It seems like it surprises people to hear about members of society who are in higher paying positions that suffer or have suffered in the past from mental illness. 

On the other side you hear about common professions where a mental breakdown is almost expected such as those known as celebrities or those in the media spotlight. Britney Spears broke down and shaved her head when the pressure became to much. Kurt Cobain committed suicide and has gone down in history with Heath Ledger and others, and after each breakdown or suicide there follows a few days of absolute shock, but then come reports of how those who were close to the person watched them slide downhill and break before their eyes. 

To many people it’s okay to place a person who suffers from mental illness in a box, and leave them isolated from the majority of the world; yet those who battle an internal illness of the mind may be the strongest in society. Imagine fighting your own thoughts every day just to get out of bed, or eat a meal, let alone drive to work, spend upwards of nine hours there dealing with tasks and other people, drive home, shower, care for other family members, go to bed, and do it over again the next day. Or consider the person who goes to therapy every other day after work to keep in control of their life. Imagine the person who has panic attacks just by walking into a room where there are people and must now lead a discussion group. There are people who “suffer” mental illness every day and those people are the ones who are pushing the world to work and keep progressing. Maybe it’s time to call those with mental illness out to run our world. 

Eric’s comment:

You make some important observations here.  

1) Mental illness is frequently overlooked because it does not always manifest in ways we easily perceive. Thus, persons who appear to be very successful or high status may suffer from mental illness without people being aware of their struggles. 

2) We have a tendency to dehumanize persons suffering from mental illness, subjecting them to unnecessary restraints, or dismissing them as dangerous, or as failures.  However, persons with mental illness may use more courage, fortitude, and mental strength in their inner lives than those who sail along through life without the problems associated with facing a mental illness.

3) Social work values force us to consider how persons with mental illness may be good role models, or we may use our social work perspectives to see that persons with mental illness offer strengths that could make contributions to others.

4) Sometimes when people have mental health problems, the people around them don’t know what to do for them.

I would like to point out that for most people with mental illnesses, a cure would be most welcome.  the fact that anyone must endure a chronic and severe mental illness is a great tragedy.  Of course we may find some ways to appreciate the nobility of how people cope with mental illness, and their struggles against diseases of the mind may give people opportunities to accomplish things that make a great different in their lives.  In some sense, all problems in our lives are cases that allow us to demonstrate our quality, or help us grow and develop. 

 Persons with a mental illness are perhaps very much like people with the flu, or persons with cancer, or persons with heart disease.  They may recover or enjoy a cure, or they may suffer for the rest of their lives.  But, just as almost everyone sometimes has a physical illness, diseases of the mind or brain abnormalities strike almost everyone at some point.  Depression or some related mood disorder, or an anxiety disorder, or a substance dependence, or a learning disability, or some other sort of mental illness, perhaps mild and not especially dramatic as a source of impairment to functioning, afflicts almost all of us at one time or another.  The psychotic disorders tend to be the most florid and interesting, although personality disorders and dissociative disorders are quite intriguing as well. Sometimes when people speak about persons with mental illnesses it seems they really only mean these sorts of things.