The Revolving Door, or Why Are There So Many People with Mental Health Chalenges on the Streets of Santa Barbara

The other evening, I was strolling around  downtown Santa Barbara when a car filled with young people drove alongside an older, somewhat disheveled, man who was reaching into a garbage can.  They honked their horn, startling him and screamed,  “Hey Hobo!  Get a job!  Stop being a sponge!”  Given the way he was talking to himself, I assumed t he might have some untreated mental health challenges.

If you think these mean-spirited attitudes are rare in “liberal” Santa
Barbara, you are out of touch with the changes  taking place. In City Hall ,our locale is painted by some councilmembers as a service-providing “magnet” talked about by those without homes all over  the country.  Or consider the  tone of  comments left on  our online news outlets when they run stories  about the homeless.  An article appeared in The Daily Sound on February 24th 2011. It was about  in the “Daily the struggles of “residents” to “take back” Cabrillo Ball Field from the homeless.  Of the 15 comments,  half  used disparaging words to describe our neighbors on the streets, including “bums,” “vagrants” and “undesirables”.  Two writers compared the folks who congregate at the park to “debris” needing to  be swept away with a broom. Several implied that the life-sustaining services of non-profits provide are part of “the problem.”

The “Hobo" comment  and the online reader responses share some
common treads: Those who live without homes are seen as lazy, as
feeding off the system and as a “problem.”  Social scientists and survey researchers confirm these attitudes among Americans generally.

Most Americans see homelessness as the outcome of personal choices and or qualities of being.  In our society, people are deemed responsible for their own economic fate.  This individualistic orientation is seenin the reasons people give to survey researchers when asked “why are
there poor people in this county?”  They  emphasize personal
traits, such as lack of effort, thrift or talent as factors that  lead to poverty,  minimizing the structural factors such as corporate downsizing, lack of jobs, or inadequate  schools. I’d like to explore some of these “structural” barriers that keep one group of people on the streets. Rather than blaming these victims of poverty,, I’d like to  highlight t problems
in  our social systems  that prevent some folks from moving
forward productively.  My focus is on those with severe mental
health challenges, including those who are also substance abusers.

Research on the homeless mentally ill acknowledges both types of
causes: structural and individual.  Examples of structural causes
include , the housing market, the structure of the economy generally and social policies.  Overall, structural barriers are societal—they point to the ways  social systems operate and are outside the control of the person.  If the unemployment rate rises, that is a structural cause of homelessness.  If the amount of
available and affordable housing goes down in an area, that is a structural cause
of homelessness. If access to  affordable rehabilitation services
for drug and alcohol treatment is cut off, , that is a structural barrier
for people with addiction issues  who want to get off the street.  If our County's mental health services or our City's Housing Authority have services  that are difficult to obtain, confusing or inaccessible to those with  mental health
illnesses,  these can be structural barriers.

In contrast, individualistic causes focus on personal behavior, and
can often result in “blaming the victim”.  Examples of perceived
individual causes include substance abuse and lack of a work ethic.
If people give up hope and stop trying to get off the street, that is
probably perceived as an individual cause of homelessness.

    Clearly, individual and structural factors interact with each other
and are often related.  For example, alcoholism and other drug
challenges are typically perceived as  personal problems.  Many
people who have had substance abuse issues have gone through
treatment, continue to work on their recovery and are currently “clean and sober.” This shows how personal choices can and do change.  But if the help needed to get off drugs and alcohol is absent or  unaffordable that is a

Tripled Challenged: Homeless, Mentally Ill and Addicted

Consider these facts.  About 50% of homeless people suffer from mental health issues. About 25% have serious mental illness, such as bipolar disorder, schizophrenia and chronic depression.  About 50% of individuals with severe mental illness are affected by substance abuse too.  These figures
are often disputed and one of the exciting aspects of the “vulnerability surveys” conducted by the Common Ground volunteers at in early  of March,  is that we will finally have data on who is on the streets and what types of problems they face.

My title, “The Revolving Door,” comes from the fact that people with
co-occurring disorders (that is mental health issues and substance
abuse issues) constantly recycle though a life on the streets and in
and out of health care and the criminal justice systems without
getting the  treatment programs they need.  Dually diagnosed
people are the most difficult to stably house and treat due to limited
availability of integrated mental health and substance abuse

I see the crisis in mental health care all over the streets of Santa Barbara.  A short walk from Stearns Wharf up State Street to the Public Library on Anapamu  any day of the week will reveal the severity of the problem. In eleven blocks, there are far more than eleven people who seem to be severely
mentally ill and living on the streets.  Likely there are more than a
couple of dozen.

But why? Our society potentially provides severely mentally ill
people with SSI / SSDI benefits and our Housing Authority is
known for its outstanding supportive housing (Section 8) program. Why, when someone could be getting a monthly check and living in supportive housing, are so many severely mentally ill people sleeping in doorways and picking food out of trash cans?  My goal is to explore why this situation exists and  suggest some solutions.

It is by advocating for structural changes in institutions
that serve the homeless mentally ill that I hope to encourage us to
move beyond the “socks and blankets” types of charity solutions, which offer much-needed “band-aid” solutions to immediate needs, but do nothing to change the situation.

Here are some “structural” barriers that prevent people with mental
illness from being able to transition off the streets and become more self-sufficient:

1) The amount of affordable housing supported by HUD in our county has gone down drastically since 1980.  The overall amount has to increase so that the percentage going to those who are on the streets and those who are disabled can increase. This country is in a “permanent housing crisis,”  according to Peter Marcuse and Dennis Keating, two respected urban housing experts.

2.) The lack of SUPPORTIVE housing for those with mental health issues is also important. Our City and our Housing Authority have garnered much praise for building the El Carrillo apartment complex, which took people right from shelters and transitional housing programs , placed them into attractive studios and provided  mental health and drug and alcohol treatment support when  needed.  To place people with lots of
challenges in housing without assistance does not work. While more of this type of housing is in the works (Artisan Courts is soon to be
opened by the City's Housing Authority), even more is needed to deal with the numbers on our streets who need it.

3) The legal system must change!  My experience in working with dually diagnosed  homeless populations that we are very quick to send people back to prison or jail for minor violations of their probation or parole, and a lot slower at giving them the integrated services they need.  While our City has an outstanding Restorative Policing team that seeks to avoid re-incarcerating folks who really need treatment, it can only deal with a small percentage
of the people who need it. About 20 people are on their list.  Officer Keld Hove from the Santa Barbara Police Department does outstanding work here.  Outreach workers have come to regard him as a tireless advocate for our most challenging cases.  Unfortunately, he is the only person on the police force doing this work, and there is an immediate need for another!

4) Another legal matter concerns the implementation of something like Laura's Law.  This would mandate some involuntary psychiatric treatment for  severely mentally ill people. Can a psychotic person really give "consent" to treatment they do not understand?  In our current situation, the courts often force mentally ill people to be released to the streets where they live in doorways and pick food out of trash cans while getting none of the care they desperately need. The pendulum has swung too far in the direction of protecting individuals rights.

4.) We need to increase number of outreach workers who can help
people apply for public benefits and services and decrease  paperwork and other barriers that make these services difficult to obtain.  For example, to access services, a severely disabled person needs to fill out complicated forms, make endless appointments and hop through countless
hoops.  I’ve seen that when a person has a family member  acting
as a part- time advocate, bringing the person to appointments and
assisting with the paperwork, the person  fairs far better than
someone without such assistance.  I have seen people forced to restart the whole benefits application process over again because they missed two appointments. Overall, we need to make the process of getting off the streets more "user-friendly" for folks who’ve had  lots of trauma, and are full of anxiety.  They might be "service resistant" because of all these institutional barriers!

5)  We need to work with our community hospitals  to allow uninsured people who are in psychiatric crisis to be admitted.  Often there are empty beds on the psychiatric wing of Cottage while fully psychotic people wander the streets. Currently, Emergency Room treatment is provided, but those  who need to be admitted are quickly discharged.  We need to insist that this level of treatment for severely mentally ill homeless be a part of the hospital's contract with the county.  We must not take no for an answer!  They CAN afford this!  (Remember the cost of the new hospital that is being built!)

6) The number of treatment beds for people with addictions needs to increase.    Moreover, we know that mental health stabilization and addiction treatment must be integrated for the dually diagnosed.  We need a low-cost residential treatment facility that doesn't deny care to the dually-diagnosed.  As someone who spent a year at the Santa Barbara Rescue Mission, I can attest to the great people working there and life-saving  services provided. But they are not equipped to care for severely mentally ill people.  When the Salvation Army's Adult Rehabilitation Center (ARC) program left Carpinteria, our area lost 80 beds for men in crisis seeking to transition off the streets. This was a devastating  loss to our community.  Our county also lacks a medical detoxification center for the uninsured and indigent.  Our only one, the Cottage Rehabilitation Center, costs tens of thousands of dollars for a 30-day stay.

7)  Santa Barbara County's mental health department, ADMHS, which also oversees all substance abuse treatment, needs  a Forensic ACT Team. This would be a  a street-wise team of mental health professionals, addiction specialists and psychiatric social workers, combined with caring and compassionate ordinary citizens (perhaps from the faith communities). This team would be trained not to give up on people, but to  meet them  where they are and tirelessly advocate for those who might be  mean or angry or rude or frustrated or traumatized.  Doctors Without Walls is an outstanding volunteer effort leading the way in this type of  street medicine and the County needs to follow suit.

We need to build the political will to make these changes happen.
It is only when our community decides it is ready to end the problem of severely mentally ill people existing on our streets that things will change.  Even in times of economic depression, progress is possible.  And ordinary citizens can take the lead. Consider Suzanne Riordan, the founder of Families Act!. She is a tireless advocate working  to change the situation for the  dually diagnosed.  Recently, I joined with her to mount a Community Forum as a part of Survival Santa Barbara, a social justice project emerging from the Unitarian Society of Santa Barbara.  Its goal was to raise funds for the  Freedom Warming Centers. And indeed, the project raised over $25,0000 to keep the warming centers open during inclement weather.  This demonstrates what ordinary people and faith communities can do to improve the situation for those suffering on our streets.