Housing alone won’t solve homelessness. California must expand its mental health system

BY PATRICIA FONTANA

NOVEMBER 6, 2023

I have learned a lot about how easy it is for someone to fall through the cracks, especially when it comes to mental health care where all those cracks are yawning abysses.

My son lives with a serious mental illness, or SMI. He was diagnosed with bipolar disorder when he was a student at UC Berkeley. But like many with these disorders, he could not recognize his illness and refused treatment.

He went from the dorm to couch-surfing with friends to living in his car. When he lost his car, he was sleeping on sidewalks or on the heating grates outside university buildings where he once attended classes. He lived on the streets for over a dozen years, despite actually having access to housing for most of that time.  

I have learned that you can’t solve homelessness without vastly improving our public mental health system. Without timely treatment and needed interventions, those with a serious mental illness deteriorate and lose housing.

SMI seriously impairs a person’s ability to function. So I am talking about neurological disorders like bipolar disorder, schizoaffective disorder and schizophrenia. Estimates suggest at least 25% of the unsheltered population have SMI. A UC San Francisco survey found that 82% of people who are homelessness have experienced a symptom of mental illness in their lifetime.

Some sleep on the streets. Others live in abandoned buildings or cars, shuffling between emergency shelters. Living on the streets, people deteriorate. They develop bad habits and self-medicate with substances to dull the misery and humiliation.

After a while, they normalize the conditions of homelessness. Sometimes they romanticize the lifestyle and come to prefer it. It seems inconceivable that someone would prefer to sleep in the cold on a piece of cardboard and refuse a warm bed, but it happens.

It happened to my son.

Finding housing for anyone in the Bay Area is difficult. Moving from homelessness back to being housed is even more challenging. For those with untreated mental illness it is next to impossible. Because of the severity of these illnesses, people are often unable to work and rely on disability payments. That amounts to roughly $900 per month, so without subsidies these individuals have little chance of affording housing in costly regions like the Bay Area.  

Those with a serious mental illness also are disproportionately incarcerated and this prolongs homelessness. Many families are told that to increase the chances of qualifying for treatment, they should kick a loved one out of their house, place restraining orders against them and file criminal charges. There are not enough treatment beds, but there is room at the jail.

An estimated 40% of inmates in the Santa Rita Jail have a mental illness, with up to 25% diagnosed with a serious mental illness. A court settlement forced the Alameda County Board of Supervisors to spend over $300 million to improve treatment of the mentally ill in Santa Rita Jail. Several jails in California are under similar court orders. Those resources should be spent providing treatment and housing in the community so that those with SMI don’t wind up in jail in the first place.  

Finding a way to house this vulnerable population is challenging, but it is a challenge that must be met – not only on humanitarian grounds, but also for practical reasons. Servicing people on the streets is more expensive for taxpayers than stabilizing them in housing. But taking people straight from the streets and placing them in housing without supports to address their mental illness is a recipe for failure.

People experiencing psychosis frequently hear voices and may respond loudly. They may become agitated and roam the halls yelling and disturbing other tenants. Many have hoarding behaviors that can lead to evictions.

Aside from the way their behavior impacts others, mental illness creates internal obstacles that prevent people from accepting and maintaining housing. Those with psychotic disorders are often paranoid. They may start to have delusions or obsessions that cause them to abandon housing. They may think that neighbors are spying on them or plotting against them.

To successfully transition people with serious mental illnesses off the street, we must include supports that go beyond providing four walls. There is no one size that fits all. Counties and cities in California need to provide a range of housing types appropriate to individual needs – needs which may change over time.  

There are those who need 24/7 supportive services, including medication management and help with daily tasks, the types provided by so-called Board & Cares or adult residential facilities. Unfortunately, there are so few care facilities in California, and many of them, including the ones that are licensed, do little more than warehouse people. It is difficult for owners to hire and maintain trained staff and high-quality facilities on the meager compensation they receive from supplemental income and government subsidies.

At the other end of the spectrum are people who can handle and who need greater levels of autonomy. They can live successfully in rent-subsidized units integrated into the community while accessing off-site services.  

Between those two poles, it’s clear we need a range of housing options – both temporary and permanent – that provide varying levels of structure, support, privacy and autonomy. These include short-stay respite centers for stabilization when transitioning from higher levels of care such as hospitalization, and long-term supportive housing that provides services such as on-site clinicians and case managers, housekeeping assistance, communal meals and activities, and life skills and vocational training to help individuals reintegrate into the community.

Importantly, people must be assessed and placed in the setting that provides the appropriate level of care, and they must be able to move fluidly between these levels as needed. If they destabilize, they may need to move into a higher level of care.

As we build housing infrastructure we must also rebuild our public health system. We need more hospital beds in better hospitals and we need more outpatient services. We need to help people even when they don’t realize they need the help. That means changing outdated laws that prevent people from getting the care that can set them on a path to recovery. The laws that underpin our current system were written decades ago when little was understood about these complex disorders and few treatment options were available.

At all levels, it’s important not to ostracize and isolate the mentally ill. We must find ways to welcome them into our communities. We now have access to better medications and therapeutic interventions that can free people from the prison of psychosis and allow them to live with dignity and hope.

GUEST COMMENTARY WRITTEN BY

Patricia Fontana

Patricia Fontana is a mother, activist, architect and longtime Berkeley resident. She co-founded Voices of Mothers and has served on various Alameda County Behavioral Health Care Services committees. She is a steering committee member for Families Advocating for the Seriously Mentally Ill.

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