yeah i’m sure there are tons of those and that money has nothing to do with it. everyone on the street is a crack whore junkie and deserves what they get according to doctors.
Most doctors that i have heard talk about the issue are begging to be able to help the people on the street, but are unable to due to conservatorship laws that prevent them from giving proper treatment. The primary issue is that the streets have become an open air asylum where the resolvable addiction and mental illness is left untreated.
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And what would “proper treatment” be, in the minds of the doctors to whom you’ve spoken?
Maybe your state differs, but I work in the mental health field and worked at a county ER for a yr full time (and was there for training intermittently for several yrs prior). So I have some familiarity with treating the chronically and severely mentally ill.
A problem as big as the homelessness issue (I’m in California) isn’t going to just have one cause, but conservatorship laws (unless they’ve changed substantially in the past 10-15 yrs, which I’m pretty sure they haven’t) don’t prevent effective treatment.
You can conserve all the people you want, but when there’s not enough (or any) beds at state hospitals, there will be no place to send patients who are on conservatorship. And, from a purely practical standpoint, conservatorship can be more about placement in a long-term facility than it is about the day-to-day administration of medication(s).
I would say an equally big problem is that insurance and Medi-Cal (Medicaid in other parts of the country) punish hospitals for keeping patient for more than 3 days but refusing to pay for additional treatment. I was under the strong impression when I worked in the ER that many of the inpatient psychiatric units that accept Medi-Cal (who would accept our patients for transfer) simply kept the patients for 3 days and then would discharge, regardless of the patient’s state, because they suspected it would be a fight to get more payment for a longer saty. They’d happily accept the patients again from us, keep them for another 3 days, and then would stop accepting the patient altogether for the calendar yr when the benefit had run out.
And then the outpatient clinic at county facilities are typically overstaffed (and, until the past few yrs, very low paying). Hard to provide continuity of care when either no one wants to work at the clinic (or when the ones you can hire are not exactly good clinicians). The county has finally decided to join the wage “arms war” btw Kaiser and the prison system and increase salaries (to a startingly high amt, actually).
Sure, the laws might make things more complicated. But some of the old timers who were my supervisors think that the domino effect started when funding was cut for state hospitals.
Not sure how “resolvable” you think these issues are. We do not understand the fundamental mechanism for any defined mental illness (except for those that are consequences of medical illnesses), so resolution is… difficult.
If one of the doctors you spoke to use the term “resolvable,” I would think that genuinely funny, if it weren’t so tragically wrong.
Back to the topic.
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This is exactly the point. You cant treat addiction in 3 days. It takes long term care to make any progress with and to start to bring someone back to being functional. Without a means of getting someone into treatement and keeping them there, theyre right back on the street, spiraling to the point where things arent “resolvable”.
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you can thank Ronald Reagan for that one.
that’s what prisons are for these days.
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This was my experience as a Public Defender in LA County. I represented many homeless defendants with mental health issues who needed help not incarceration. The county resources were woefully inadequate so most of my clients were sentenced to pointless jail time. Proper mental health resources would have benefited my clients but the system is geared towards punishment.
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The movement actually started with the 1963 Community Mental Health Construction Act. Those mental institutions that got closed had a bit of a problem with being really terrible places to live. Shutting them was a well intentioned idea to try and change how we provide mental health. The 1981 omnibus spending bill was terrible though because it removed finding for a lot of the outpatient care that was supposed to replace those institutions.
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Oh, please, not the blame Ronald Reagan trope. He was governor 50 years ago. There’s been plenty of time for subsequent legislators and governors to remedy whatever of his ancient funding cuts that you assign blame for the current crisis of mentally ill and drug addicts wandering the streets. This includes complete democrat control of Sacramento, including the supreme court in for the past 20 years. Apparently, they are blameless.
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Some of the oldtimer hippies I’ve talked to over the years insist Ken Kesey’s One Flew Over The Cuckoo’s Nest was the final cultural trigger to decentralize mental health treatment, since it so successfully galvanized public opinion even in book form (movie was 1975).
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So a Federal spending bill from 40 years ago is to blame for the droves of insane and/or drug addicted people living on the streets of San Francisco, LA, San Diego? Did it do something to prohibit the state of California from solving the problem on its own in the last four decades? And none of the other subsequent state or federal administrations that could have restored that magical problem solving funding are to blame? Or, rather, has oodles of cash been thrown at the issue by all levels of government to no avail… For example, The LA Homeless Service Authority spends a billion a year in city, state & federal funds with a miniscule success rate. But blame Ronald Reagan.
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Last post from me on this topic b/c I’ve already gone too far astray, but, respectfully, I’m not quite sure what the relationship is btw what you’ve stated and conservatorship.
The LPS Act is what governs involuntary hospitalization (and conservatorship is only one part of that Act). Involuntary hospitalization is technically not allowable if the only issue are substance abuse issues. But that might be clinically impactful because lengthy hospitalizations are not thought to be a particularly effective treatment for “pure” substance abuse.
I’ve treated plenty of wealthy people, too. I can assure you that their addiction issues do not resolve anymore quickly than those who are unhoused. They just have the resources to hide the issue from others (including the general public) more easily.
Substance abuse is an extraordinarily difficult issue to treat, and anyone even implying that it would be resolvable if they (either the provider or pt) could just access the “right” treatment is… naïve, at best.
I’m not sure if you (or the doctors to whom you have spoken) are operating under the assumption that substance abuse is a major cause of homelessness?
While I’m sure there are some homeless people for whom substance abuse is the primary issue, I think a lot of those who are homeless were using drugs to help them cope w/ the homelessness and/or whatever the primary issue was (such as psychosis). And, given the methodological problems involved in studying mental health issues in the homeless population, I would be very surprised if they were any high-quality data suggesting otherwise.
Lengthy hospitalizations might be helpful for, say, primary psychosis, but psychosocial treatments and long-acting injectables (all of which can be administered on an outpatient basis) can result in long-term stability. If someone has a strong history of being repeatedly admitted, the treatment team can apply for LPS conservatorship so that treatment such as long-acting injectables can be given involuntarily. So conservatorship laws don’t really interfere with that, either.
In CA, at least, the LPS Act is written in such a way that those are “gravely disabled” (and much of the homelessness population might match this definition) are actually eligible for the longest involuntary hospitalizations.
In short, I’ll put it this way: while I’ve frequently thought over the course of my ~15-yr career that insurance (and the financial resources of a patient, b/c of how screwy insurance is) really interfere with effective treatment, I cannot say that I have ever thought that the existence of the LPS Act greatly interferes with effective treatment.
I’m guess I’m trying to say that I really don’t know don’t quite understand what the doctors who you’ve spoken to are getting at. But, again, the laws in your state might be quite different.
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Particularly in light of the following, from wikipedia:
“In response to the ensuing homelessness crisis of the 1980s and after many years of advocacy and numerous revisions, President Reagan signed into law the McKinney–Vento Homeless Assistance Act in 1987; this remains the only piece of federal legislation that allocates funding to the direct service of homeless people. The McKinney–Vento Act paved the way for service providers in the coming years. During the 1990s homeless shelters, soup kitchens, and other supportive services sprouted up in cities and towns across the nation. However, despite these efforts and the dramatic economic growth marked by this decade, homeless numbers rose and remained high from 1990 to 1999 according to the “coalition for the homeless” webpage. {{[38]}} It became increasingly apparent that simply providing services to alleviate the symptoms of homelessness (i.e. shelter beds, hot meals, psychiatric counseling, etc.), although needed, were not successful at solving the root causes of homelessness. The United States Interagency Council on Homelessness (USICH), a federal agency contained in the Executive Branch, was established in 1987 as a requirement of the McKinney–Vento Act of 1987.”
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I’m not a medical expert, so I am sure I am doing a poor job of summarizing the nuances of their points, but we don’t seem to be saying much different, at least as far as root causes and the relationship to the earlier discussion here regarding housing pricing.
That is to say that mental illness and addiction is a primary factor in homelessness, treatment for those is a long term process, and the current system does not adequately provide long term solutions, but rather spits them back out on the street immediately.
Thats a medical issue, not a housing issue.
The doctors that i have heard speak on the issue are in California.
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The politico’s answer for it is, wait for it… “legal injection centers”. How brilliant an idea that is.
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This is another one of those questions that essentially boils down to a couple simple options. For this small segment of the population state/federal government pays to house the people in a crummy apartment (and give the drug users heroin ), incarcerates them or provides them the medical care to allow them to live as independently as possible. Or of course just let them live on the street.
There is no market based solution to house drug addicts (until they are rehabilitated) or the 1% of the population that are mentally incapable of working.
Want to know what the cheapest option is to clean the streets up? Give the drug users free heroin and a crappy apartment. The Dutch figured this out years ago. Proper healthcare costs a huge amount. Putting them in prison is a $30k plus per year per person proposition.
There isn’t an easy solution. It’s pick your poison. Every option is either unpalatable or very expensive.
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I know I said I was done, but my clarification will not be as long winded as my other posts (I hope). 
And I am learning quite a bit from the thread.
Well, possibly, actually. I’m not familiar w/ the intricacies of the Omnibus Bill from 1981, but it apparently cut funding for nursing homes that also treated people who were primary mental ill (and required that the patients have significant medical issues). States can’t re-define something explicitly stated in a federal law. And if you were counting on tens of millions (if not more) per year from a source, it’s not really possible to make up that kind of windfall w/o significantly raising taxes (and we all know how popular that is) or cutting funding from other program.
And Prop 13 has really screwed up the state’s revenue stream for about 50 yrs (and counting…).
I am familiar w/ the other things mention in the thread about this sub-topic, but I was not familiar w/ this Act at all. It’s actually rather hard to find much info about the original version that passed, since what’s easily accessible on the internet is basically a repeat.
From the little I can find, whatever Reagan signed was apparently only a small portion of what had originally been proposed. And, assuming I correctly access the proposed bill, it doesn’t do much in the way of concrete action.
Academic writings about the Act only reference its effect on public-accessible education for homeless children (most of which came from amendments in subsequent administration), so I am actually unsure that the original bill did anything at all.
I actually do not know if drug use is a primary factor is homelessness. I think it is a strong co-occurring factor, which is quite a different thing from it being a primary facator.
The system makes it more profitable to spit them back on the street more quickly. It certainly does not mandate it, and there are definitely work arounds (that are actually encoded in law and thus are not a secret) in many situations.
I guess a strong secondary point I was trying to make is that I do not know the motives of why the doctors you’ve heard do not use, have not discussed, and/or do not advocate for strengthening those parts of the law.
Yes, I agree with that. Having said that, I was not under the impression that politicians (at least in LA, where I cannot escape the election ads) were strongly tying the housing crisis to homelessness specifically. I was under the impression that the some of the general public was making such associations (and I agree that association is completely stupid).
I originally found the idea of needle exchange (which is a step removed from government funded drugs) to be quite challenging.
But then you work w/ IV drug users for even a relatively short period of time and discover that the biological imperative for them to use is so strong, that you might as well help to curb the negative behaviors associated with IV drug use (b/c you really cannot stop the IV drug use itself).
I am not advocating for or against socialized medicine, but one advantage of socialized medicine is that it’s generally much easier to obtain data to help determine if such programs are effective.
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Exactly. That’s why I find the usual conversations about these issues to be so frustrating. I want to tell people, “Folks, the solution ain’t gonna be pretty…”
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If you listen to CA politicians, they will tell you that homelessness is exclusively a housing issue and that the mentally ill/addicts are an inconsequential fraction of the homeless population. To the point of actively blocking many of the medical treatment based solutions.
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Even renaming it ‘unhoused’ versus ‘homeless’. Words do matter, and more attention should be paid to words with an agenda behind them.
It was offered as a simple refutation against a pointless blaming, when I believe we can all agree the issues themselves are not ‘partisan’, insomuch as the solutions may be. I gather from a quick follow of your link that this act was funded for two years, established a federal advisory council which forced states to report to, and largely bolstered existing systems (possibly establishing a few along the way), but my takeaway is this is the most prominent federal legislation passed by Congress directly addressing the homeless crisis in the late 1980’s. I can confirm SRO unit occupancy exploded in the tenderloin, china town and Civic Center/upper Market areas during this time, and the City ‘seemed’ to be cleaning up its act. It still had a long way to go to get where it is now, as untreated wounds tend to worsen.
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