Round and Round We Go: Or the Way Services Work for People Who Are Homeless

Eduardo may very well be the neediest homeless person in San Diego. He has visited the Emergency Room (ER) 500 times over the past year, sometimes because he’s run out of food and called 911, and other times because he’s been hit by a car or found by paramedics passed out on the sidewalk. At age 69, he’s dealing with a daunting combination of chronic alcohol and methamphetamine use, schizophrenia and early-onset dementia exacerbated both by drugs and life on the streets.

Yet despite being someone who clearly needs care from multiple systems simultaneously, Eduardo has frequently wound up getting help from none of them—and been quickly released back to the streets.

Serious mental illness and substance use disorders are common among people experiencing homelessness, but the prevalence of cases like Eduardo’s is hotly debated. The federal government estimates that in 2020, there were about 580,000 people who were chronically homeless in the United States, of whom 120,000 (or about 20%) had a serious mental illness and 98,000 with chronic substance use issues (17%).

Other figures, however, put the prevalence much higher—at more than 75% for both, among unsheltered people nationwide. The fuzzy boundaries of when substance “use” becomes “abuse” or when the understandable distress of being unhoused becomes a diagnosable mental health condition help explain the disparity.

These debates matter because they drive perceptions of the origins of homelessness and appropriate policy responses. Advocates for “Housing First” argue that housing costs are the core drivers of homelessness, and the solution is to give people homes—with voluntary services attached.

Meanwhile, critics argue that the closure of large, state-run psychiatric facilities (which at their peak in the 1950s interned 550,000 Americans) abandoned people who needed treatment, and the solution is a more aggressive push to get people into treatment and rehab, involuntarily if need be.

Siloed Systems

As a sociologist who has interviewed more than 200 stakeholders in the mental health system in California, I’ve seen how individuals like Eduardo push both proposed solutions to their limits. They are unlikely to thrive in independent supported housing and unlikely to find medical services able and willing to treat their complex mix of medical and behavioral health issues. Cases like these will present a growing challenge as America’s homeless population rapidly ages.

I spoke to multiple clinicians at one of the hospitals Eduardo frequents (as is the case in most sociological research, the people I interviewed are anonymous). A psychiatrist working in the ER lamented the “moral injury” he felt when “time and time again you have to click the discharge button because there’s nowhere to send anybody.”

In 2020 there were about 580,000 chronically homeless people in the U.S., of whom 120,000 had a serious mental illness.

Indeed, it seems just about everyone has what seems like a good reason to refuse to serve Eduardo: a medical unit in the hospital is reluctant to take someone who is likely to be stuck in a scarce bed while waiting for a placement in a nursing home, which might be reluctant to take someone with serious behavioral issues.

Substance abuse programs, one psychologist working at the hospital pointed out, “require some fairly decent cognitive function to engage appropriately” with voluntary, self-improvement recovery programs, which rules out someone with dementia. Meanwhile, county Adult Protective Services wouldn’t take the case because they don’t traditionally serve adults who are homeless.

Divided Pathways

In theory, states have a range of legal and medical tools at their disposal to protect highly vulnerable adults like Eduardo. His psychiatrist applied to place him on a conservatorship (in other states this is usually referred to as a “guardianship”), a legal procedure affecting 1.3 million Americans by which a court appoints a third party to make decisions on a person’s behalf.

But when Eduardo’s doctors applied for a “probate” conservatorship (usually for people with dementia or developmental disabilities), the county Office of the Public Guardian, which handles conservatorships for indigent persons, said he didn’t qualify because he had mental illness. When they applied for a Lanterman-Petris-Short conservatorship (for people with mental health issues), the county Office of the Public Conservator (which occupies the same office as the Public Guardian) said he didn’t qualify, because he had dementia.

His case reveals that our system was built around the idea of discrete populations that fit neatly into specific boxes—homeless, older adult, drug user, mentally ill—and thus frequently has no place for those that check “all of the above.” Although people with severe mental illness die on average 25 years younger than the general population, the population of people served by the mental health system is rapidly aging.

The system is poorly adapted to their needs. Paradoxically, one inpatient clinician working in a safety net hospital lamented, “We’re getting better at stabilizing people psychiatrically, but long-term antipsychotic use is causing a decline in physical health.” But psychiatric units are reluctant to take people with medical issues that require IVs, monitors and catheters.

These multiple systemic failures help explain the accelerating deaths among America’s homeless population. Homeless deaths in Los Angeles, for example, grew from 630 in 2014 to 1,267 in 2019, and have almost certainly worsened during the pandemic.

Pathways for Reform

Lawmakers across a range of states have proposed expanding conservatorships as the solution to people “dying on the streets.” But the issue for people like Eduardo isn’t the legal criteria: any judge would agree his condition is severe enough to merit conservatorship. The problem is a lack of infrastructure to serve people with “tri-morbidities”—physical, mental and substance abuse issues that bring them to an ER over and over again, only to find that there’s no institution willing to admit them.

America’s mental health system is poorly adapted to aging people with high medical needs.

One piece of reform should include reconsidering the privatization of the public safety net. Mental health systems using public Medicaid and Medicare dollars in the United States are largely contracted out to private agencies. For-profit chains control the majority of nursing homes and an increasing share of psychiatric beds. These institutions have strong incentives not to serve the most complex individuals and to try to send them elsewhere.

But someone in these diverse systems of care needs to be the provider of last resort. Part of my research brought me to France. The country is divided into psychiatric “sectors”—catchment areas of 70,000 people with a single, dedicated psychiatric team assigned to it. The system isn’t perfect, but it does make it clear that everyone has a place to go. Even if such an extensive public system is not in the cards in the United States, governments should do more to obligate providers receiving public money to serve the neediest individuals.

Rather than trying to pinpoint whether the root problem of the homelessness crisis is mental illness, substance use or physical health, states need to do more to address the “fundamental causes” of homelessness. California’s CalAIM program, rolled out this year, will use Medicaid money to provide “whole person care” and benefits ranging from housing deposits to fresh food. The program recognizes that the best way to respond to complicated co-morbidities is to prevent them from developing in the first place.

What reform can do for people who have already spent years neglected on the streets, though, is unclear. Clinicians eventually pressured the county into conserving Eduardo. He has now been waiting on an inpatient ward for a year, for a nursing home willing to take him.

Alex Barnard, PhD, is an assistant professor of Sociology at New York University in New York City.

Photo credit: maradon 333