JOEL ON HOMELESSNESS, MENTAL ILLNESS & DRUG ADDICTION

Overview
Housing is essential for addressing homelessness. We must also address the underlying causes of human suffering on our streets, including mental illness and drug addiction. Successful treatment is dependent on having a safe place to get well.

For people suffering from mental illness, we need enough beds for every level of care: acute, subacute, and community residential. We’re woefully lacking in subacute and community residential facilities. Addressing this will require making it a state and federal priority. We must expand conservatorship laws and support Governor Newsom’s statewide Mental Health Care Court, while also investing in a new generation of mental health facilities that can provide compassionate treatment.

We need to offer enough beds in shelters and navigation centers so people always have a safe place to sleep, while we build more units of permanent housing of all types. Tent encampments blocking sidewalks are not a viable option. In addition to shelter beds, we need transitional housing combined with supportive programs. The “tiny homes” concept is a good example.

Mental health treatment depends on housing
We won’t be able to address the mental health crisis on our streets and in our society until we create safe and stable living spaces for people to get the treatment they need.

From the New York Times: “A truly robust mental health system will have to include a range of services — not only outpatient clinics but also short-term care facilities for people facing acute crises, and some congregate institutions for the small portion of people who can’t live safely in the community.”

From the San Francisco Chronicle: “California lacks space to meet demand at all three main levels of care — acute locked beds (inpatient care that aims to stabilize patients who can’t care for themselves or risk harming themselves or others; subacute, inpatient care with slightly less intensive monitoring; and community residential, staffed non-hospital facilities that aim to help patients with lower-acuity or longer-term needs achieve interpersonal and independent living skills.”

Can San Francisco remove tents from sidewalks? 
The ability for the city to remove tents has been tied up in the courts for some time. In August 2023, a court hearing clarified that tents can be removed when a person refuses an offer of shelter and is no longer considered to be involuntarily homeless. Mayor London Breed issued this memo about the clarification of the court injunction, saying the city will do more to remove tents when people refuse shelter and services.

But it’s important to note that the court case involving the injunction is not resolved. There has been a flurry of court activity in early 2024 regarding tent encampments:

"The Ninth Circuit ordered an injunction restricting encampment sweeps in San Francisco to remain in effect as the underlying case plays out in federal district court. But the judges also asked the district court to clarify that the injunction only applies to ‘involuntarily homeless’ individuals—meaning it doesn't protect those who decline an offer of shelter or are otherwise already sheltered,” explained the San Francisco Standard. 

The trial about tents will be heard in April 2024. 

Meanwhile, the U.S. Supreme Court agreed to reexamine a case called Johnson v. Grants Pass that advocates have used to establish the right to sleep outside. The San Francisco Standard explained: “The decision to take up the case follows lobbying by Gov. Gavin Newsom, the San Francisco City Attorney's Office and other local advocates who had urged the court to clarify the tangle of laws governing how cities can respond to homeless encampments."

The U.S Supreme Court case will be heard in April 2024 with a ruling expected in June.

When it comes to RVs, City Attorney David Chiu issued this memo that outlines what the city can and cannot do.

Housing options
The court injunction against removing tents leaves City Hall with several options. City Attorney David Chiu can keep fighting the case to the Supreme Court, if necessary. Or, we could find a way to create thousands of shelter beds ASAP to satisfy the judge's order.

That would require turning unused piers and empty parking lots — any space that works — into a centralized space for tiny home cabins and RVs that offer shelter, sanitation, and behavioral health services. An organization called 2000 Open Doors has lots of ideas about how to make this happen.

To tackle our homelessness crisis, we must build all types of housing that meet a variety of needs — shelter beds, navigation centers, permanent supportive housing, tiny homes, and regular housing.

We must also address the underlying causes of human suffering on our streets, including mental illness and drug addiction. Successful treatment is dependent on having a safe and stable place to live.

For people suffering from mental illness, we need enough beds for every level of care: acute, subacute, and community residential. We’re woefully lacking in subacute and community residential facilities. Funding those facilities will require state and federal resources.

The issues of homelessness, drug addiction, and mental illness are complex. They require a compassionate approach, without sacrificing the social contract for a functioning city.

Read more about the tent removal case and the RV issue.

Drug treatment
Many homeless people suffer from severe drug addiction and the fentanyl crisis has led to a record number of overdose deaths on San Francisco’s streets.

We must acknowledge what is known as “drug tourism.” It plays a role in why some people set up encampments in San Francisco and refuse shelter. Drugs are not allowed in shelters, but they’re easy to get on the sidewalk. To save lives, we must shut down the open drug market on San Francisco’s streets.

We should have no tolerance for an open air drug market. The dealers who sell deadly drugs must be held accountable for their illegal actions. Drug users should not be criminalized, however. They need our help. But some extreme cases will require compelled treatment to save lives and the involvement of law enforcement to protect public safety.

To save the most lives, we must prevent another record number of overdoses in San Francisco. That will require utilizing a wide range of interventions: overdose prevention centers, abstinence-based treatment services, sober living facilities, detox facilities, and dual diagnosis services for people with mental illness and substance use disorders.

It is vital to offer a variety of drug treatment programs to save lives. This includes both harm reduction and abstinence, so people have options for the type of program that will give them the best chance for recovery.

The path required for recovery was outlined in a San Francisco Chronicle OpEd. It was written by three health care workers on the front line of the addiction crisis. They called on local and state officials to “develop a coordinated system that can stabilize individuals during their initial hospital stay, initiate a prompt and transparent conservatorship process, and provide placement in an appropriate inpatient rehabilitation program that can accommodate all medical, psychiatric and substance disorder needs.”

What is conservatorship?
In 2019, San Francisco adopted a state conservatorship law to give the neediest people compelled mental health and drug treatment.

People with severe mental illness who are screaming on the street and engaging in destructive and antisocial behavior often cannot recognize they need help. In these cases, we need to compel people to get treatment — for everyone’s safety.

This does not mean going back to the awful days of Nurse Ratchet and mental asylums. We should expand conservatorship laws, support the proposed statewide Mental Health Care Court, and open new institutions where people can get compassionate and effective treatment. It is not progressive or humane to let people suffer and die on the street.

San Francisco has a Behavioral Health Court for mentally ill people. If they hit or attack someone while having a psychotic episode, the court gives them treatment instead of jail time. This is good, because our jails should not be de facto mental institutions.

Yet at the Behavioral Health Court, someone doesn’t get help until after they attack someone. We should help people before they become violent.

A compassionate society takes the necessary steps to give people with severe mental illness the treatment they need.

Housing is essential for addressing homelessness. So is treatment for people suffering from severe mental illness.

In 2019, nearly 4,000 homeless people were identified as also struggling with mental illness and addiction — many deteriorating visibly on the streets. The same year, San Francisco adopted a state conservatorship law to give the neediest people compelled mental health and drug treatment.

Yet how many received help in the four-year program? Four.

The San Francisco Chronicle investigated why we’ve failed so miserably. Short answer: city supervisors made state conservatorship legislation harder to implement locally.

That’s why we needed a new state law signed by Governor Newsom that went into effect January 2024 and expanded conservatorship for severely mentally ill people.

The governor also put a $6 billion bond measure on the March 2024 ballot, which will “fund the construction, acquisition or rehabilitation of up to 11,000 new treatment beds and supportive housing units to provide the necessary capacity to serve individuals through SB43 and CARE Court.”

What is a “tiny homes” example?
A good example of using tiny homes successfully is in Austin, Texas.

Austin created a 27-acre site just outside of town called Community First Village that provides homes and services. It includes places for RVs and also something called tiny homes — 120 square foot cottages with a bed. There are community kitchens, laundry, restrooms and showers.

Residents with drug and alcohol addictions are offered treatment. Residents also have jobs doing maintenance and cleaning of the community spaces. They earn money to pay for rent, which is required. 

Even with that rule, there is an 87 percent retention rate. The project is run by privately-donated funds. Hundreds of Austin residents volunteer at the site every week.

Everyone in Austin has an investment in the community succeeding.

We can have that attitude in San Francisco. A new local nonprofit called “2000 Open Doors” is identifying sites throughout San Francisco owned by government, private, and religious entities that could hold a total of 2,000 tiny homes.

How much does San Francisco spend on homelessness each year?
San Francisco spends hundreds of millions of dollars a year addressing homelessness. Much of that actually doesn’t go to people who are homeless. Instead, it is used to keep people housed.

For example, the San Francisco Chronicle reported that two-thirds of the $250 million spent by the City's Department of Homelessness and Supportive Housing in 2017 went to rental subsidies, eviction prevention, and permanent supportive housing. In essence, two-thirds of the money spent by City Hall every year on homelessness is used to keep the problem from getting worse, with only a third going to direct services to help those currently on the streets.

We must ensure that the money is being well spent. For example, the San Francisco Examiner reported that “San Francisco spends more than $100 million a year on job training programs but lacks crucial information to gauge their effectiveness.”

The San Francisco Chronicle published an investigation into a city-funded program that shelters vulnerable residents in hotels: “Because San Francisco leaders have for years neglected the hotels and failed to meaningfully regulate the nonprofits that operate them, many of the buildings — which house roughly 6,000 people — have descended into a pattern of chaos, crime and death, the investigation found. Critically, the homelessness crisis in San Francisco has worsened.”

We should measure programs for success. Our compassion should be backed with the knowledge that we are paying for what works.

How many homeless people are in San Francisco?
The most recent San Francisco Homeless Count and Survey in February 2022 reported 7,754 homeless people, which was a 3.5 percent decrease over the previous count in 2019. Most (57 percent) were “unsheltered,” or not spending the night in any kind of temporary shelter, transitional housing, or safe haven.

A full report published in August 2022 provided more detailed information, such as westside neighborhoods in the Sunset seeing the largest increase in total homeless population.

How many homeless people in San Francisco have significant mental illness and addiction problems?
The most recent survey indicated that 42 percent of homeless people in San Francisco suffer from drug or alcohol addictions, 39 percent have psychiatric or emotional conditions, and 37 percent suffer from post-traumatic stress disorder.

In 2019, nearly 4,000 homeless people were identified as also struggling with mental illness and addiction — many deteriorating visibly on the streets. These individuals are the most vulnerable among the homeless population and require the highest level of services. Updated numbers are expected in July 2022.

HOMELESSNESS ESSAYS