The homeless health connection

Institutionalization returns as option as cities struggle with mental illness on the streets
A homeless man sleeps in a San Francisco parking lot. photo: Franco Folini

In Feb. 2016, a number of strange things will happen in San Francisco. For one, the San Francisco 49ers, who no longer play in this city, will host the Super Bowl, and many thousands of football revelers who have no intention of spending the week in Santa Clara will turn San Francisco into Super Bowl Central. The second is the strange sights, sounds, and smells those visitors will experience while in San Francisco. Locals hoping to show off their hometown to outsiders will understandably be nervous, lest those visitors experience any of these recently observed happenings in the city: a man shouting incoherently at the Powell Street BART station, a man dropping his pants and going to the bathroom on a public sidewalk, another man urinating between two parked cars, or a woman shouting incoherently at passersby near Union Square.

How did our public spaces become “like a mental ward on the streets,” as The New York Times once described Berkeley’s mentally ill homeless?

Discussions about homelessness and livability in the city often include residents complaining about the seemingly worsening problems and asking why the city doesn’t clean it up. In an August online public chat, San Francisco Chronicle columnist Debra J. Saunders engaged residents and others — including the city’s homeless services director, Bevan Dufty — in a discussion of why San Francisco smells. Residents soon turned it into a platform to complain about the public bathroom practices of homeless people. One wrote, “It is because the money designated for ‘homeless’ primarily goes to pay for nonprofit attorneys that fight to allow squatters, loiterers, panhandlers, vagrants, nudity, and defecation on the streets. I’ve witnessed first hand a man talking to himself and having a bowel movement in the Montgomery Bart underground walk area. This person was definitely mentally ill and should have been in a mental institution, not on the streets.”

Another wrote: “The deterioration has been astonishing. I have been physically assaulted in Union Square by a drugged-out homeless person, a neighbor was knocked out and had to have her teeth repaired by another, a third followed a group of friends chanting that she was going to murder them and nearly assaulted one of the women until she was overpowered by one of the men in the group. Walking to work is deeply unpleasant … I saw a man openly smoking a crack pipe in the Financial District. I do not walk by myself after 5:30 because the camps begin setting up around that time. I am a tax paying, law abiding, functional, productive citizen. I feel that the city is more interested in accommodating street people than ensuring the safety of people like me.”


It is a complex and expensive problem, and there exists a push-and-pull between people who want to focus on the human needs of the person on the street and people who find their quality of life negatively impacted and even their safety endangered by the many antisocial activities they experience, especially in parts of downtown. Making it even more complicated is that the push-and-pull can exist within the same person, with a desire to ride a bus without having to endure a raving sermon from a stranger coinciding with a hope that the homeless person gets the help that is obviously needed.

In the professional world of homeless services, there also exists a split about how to treat at least some of the people. There is a movement afoot, led by people such as former advisor to President Obama, Dr. Ezekiel Emanuel, to reintroduce mental health asylums for long-term treatment of the severely mentally ill who cannot be served by outpatient or other services offered in the community at large. It is a reversal of a trend that began in the 1960s about moving as many people as possible into the community and out of institutions, providing treatment through improved medication.

Ronald Reagan, as governor of California, is often blamed for starting the deinstitutionalization trend and not providing the funding for services, but the trend was nationwide. Reagan did play his part as governor (and later as president, when he reversed a policy of predecessor Jimmy Carter that tried to restructure treatment for the chronic mentally ill), but he was not alone, nor was it by any means a conservative versus liberal divide. Civil libertarians had argued for years against the forced institutionalization of the mentally ill, preferring that they be treated with the least-coercive methods available.

But the visibility on the streets of people exhibiting clear signs of mental illness, often combined with drug use, worries people who are concerned about their own safety as well as the safety of the homeless person.

During a July 22 debate at The Commonwealth Club over the proposal to reintroduce asylums, Dr. Dominic Sisti — one of Emanuel’s co-authors of the proposal — said people have a false assumption that mental illness equals violence. It is a “deep misconception … that seriously mentally ill people are horribly violent,” said Sisti, who is an assistant professor of medical ethics, health policy, and psychiatry at the University of Pennsylvania. “They are not by and large, unless you added substance abuse disorder, and then there could be an uptake in violence.”

“Very few people who have serious mental illness are actually violent,” agreed Dr. Renee Binder, a psychiatrist at the University of California and the new president of the American Psychiatric Association. “Most violence is committed by people who do not suffer from mental illness.”

Opponents and proponents of the institutionalization proposal generally agree that the homeless mentally ill do get handled and occasionally treated by society, but far too often that happens via the criminal justice system instead of the medical establishment.


“The mentally ill are 10 times more likely to end up in prison than in psychiatric care,” said U.S. Representative Tim Murphy (R-PA), who is also a psychologist. Murphy and colleague Representative Eddie Bernice Johnson (D-TX) have co-sponsored a bill, the Helping Families in Mental Crisis Act, which reforms programs and provides for services for the most difficult cases.

The quality-of-life effects of the criminalization of homelessness combined with the inadequacy of treatment for them in the community results in problems for people who are bothered by the outbursts and antisocial behavior noted above and for the homeless themselves. People living on the street “are much more likely to get all kinds of medical conditions, whether it’s infectious disease, pneumonia, problems with their circulation and gangrene, or they cut themselves and don’t get treatment for it and before you know it, they need to be hospitalized,” said Binder. “Those people in general are going to hospitals, and once someone is hospitalized medically, the costs are astronomical. And who’s paying for it? Our tax dollars are paying for it at the county hospitals. So homelessness is very expensive.”

Despite assumptions that the city’s housing shortage is fueling homelessness here, the number of homeless has remained fairly steady (roughly 6,400 people). That number might be a lot higher if the city didn’t spend a lot of time and money providing shelters, permanent housing, and other services to the at-risk, including veterans. In May of this year, Mayor Ed Lee announced a plan to provide housing for 50 formerly homeless veterans and 50 low-income families at a new 101-unit project in Mission Bay. The project’s funding leverages $5 million raised from tech philanthropists, including Ron Conway, Marc and Lynne Benioff, Peter Thiel, Sean Parker, and others.

District 2 Supervisor Mark Farrell has made the homeless issue a priority, and he has pointed to projects such as one that would change homeless shelters from overnight transient bunks — where people are forced to leave in the early morning and are not allowed to stay with their partners, belongings, or pets while in the shelter — into housing-lite, where they would have a shelter all day if need be, and they could keep near them the things, pets and people they value.

But about one-third of the homeless are believed to have mental illness of one kind or another, and solutions for them involve a long-term housing-plus-services approach.

Dr. Binder, who opposes reinstitutionalization, argues for a housing-first approach, saying that studies show that with housing, even people with severe mental illness can be better engaged with treatment. She also supports San Francisco’s behavioral health court, which tries to divert the severely mentally ill from repeated incarceration and instead connect them to community treatment services.

Keeping people who need mental-health treatment from causing problems for themselves or others will require commitments from the community to fund and continue the services they need, as well as frameworks of case workers for some or institutionalization in extreme cases that ensure the treatment is continued by the patients.

That will not be solved by the time the nation’s football fans descend on San Francisco’s streets in early 2016.

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