January 4, 2016; Los Angeles Times

Last week, the Los Angeles Times reported on plans to finance new housing for homeless people with mental illness. In the article “California legislators propose spending $2 billion to build housing for homeless,” Gale Holland reports on plans by state legislators to enact a bond levy that would build new housing for the homeless mentally ill. This proposal comes in the wake of Mayor Garcetti’s “almost” declaration of a homeless emergency. With this new plan, state legislators are explicitly reacting to California’s dubious reputation. Senate President Pro Tem Kevin de León is quoted in the article as saying, “L.A. has the unfortunate distinction of being the country’s homeless capital.”

Under the proposed state plan, California will issue bonds to finance the development of what appears to be permanent supportive housing for mentally ill homeless individuals. These bonds will be paid off over 20 years with revenue from the so-called “millionaires’ tax” for mental health services that California voters approved in 2004. The plan also calls for a separate appropriation of $200 million that would support short-term rental assistance for the mentally ill homeless until new permanent housing can be built. “Officials estimated the construction funds, combined with federal and local money, could generate 10,000 to 14,000 units for California’s 116,000 homeless people, more than 60 percent of whom live outdoors.”

Since the 1970s, when California led the nation in shutting down state mental hospitals under Governor Reagan, states have been searching for ways to address the problem of balancing mental health and public safety needs. When deinstitutionalization of the mentally ill was first proposed, the “plan” called for released inmates to find affordable housing in the community and support from a community mental health system proposed under the Carter administration. In 2013, Slate writer Dr. E. Fuller Torrey documented that history in an article entitled “Violence, the homeless, mental illness,” which blamed Reagan for creating homelessness. A less overtly political analysis of the deinstitutionalization movement is found in a report by the Treatment Advocacy Center called “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals.” This report makes the case that “many states appear to be effectively terminating a public psychiatric treatment system that has existed for nearly two centuries. The system was originally created to protect both the patients and the public, and its termination is taking place with little regard for the consequences to either group.” The legacy of deinstitutionalization has been chronic homelessness, criminal incarceration, or some mix of housing and services.

While chronic homelessness has been recognized for many years, the impact of the criminalization of the mentally ill has gained public attention more slowly. The incarcerated mentally ill are less visible than folks on Skid Row. Last year, Cook County hired a psychologist to run the county’s penal system in recognition of the extent to which that system serves mentally ill inmates. Slate’s Dahlia Lithwick says:

The abuse, neglect, and tragic lack of foresight in that system is emblematic of a problem that exists throughout this country. It’s a problem that will only worsen unless we distinguish between mental illness and criminality and return to policies that actually treat inmates who are ill, rather than brutalize them.

For mentally ill people who are less obviously a risk to public safety, homeless practitioners have evolved a mix of interventions that cobbled together housing and services. This is an area where practitioners, looking for more permanent solutions than “emergency shelters,” were ahead of public policies.

Housing for non-violent mentally ill homeless individuals was found in aging public and privately subsidized housing developments originally designed for seniors. As better off seniors moved to newer developments, owners of older developments in less desirable communities turned to younger, disabled individuals to fill their vacancies. Service Coordinators hired by property management companies with HUD funding were increasingly called upon to provide services to this new population. Mixing seniors and younger disabled individuals was often not a comfortable “fit” for the seniors and may have contributed to the passage of the Housing for Older Persons Act in 1995. A variation on this ad hoc housing-plus-services model has been the use of “board and care” homes, where mentally ill or dependent seniors can get “room and board.” Just this year, the Pittsburgh Post-Gazette highlighted these informal systems in “No Safe Harbor: McKees Rocks, Homestead left with clusters of mentally ill residents.” The article depicts how an ad hoc blend of mentally ill individuals, affordable housing, community-based health and social service programs, and local police have created a social ecology that is an alternative to living outdoors or in a succession of temporary shelters.

Over the past three decades, these ad hoc blends of services and housing for the mentally ill became more formalized as a strategy called permanent supportive housing (PSH)—permanent because it’s not “emergency” or “transitional” housing, and supportive because mental health and other services are a part of the “housing” package. The Corporation for Supportive Housing (CSH) has become the torchbearer for this strategy.

Over the same period, other groups of homelessness providers were innovating a strategy called “Housing First,” which is built around the principle that homeless people should be housed unconditionally before being provided with medical or social services to address the underlying causes of their homelessness. Ironically, Wikipedia identifies Los Angeles as the birthplace of the “Housing First” movement. It may be helpful to think of “Housing First” and PSH as contrasting rather than competing strategies.

In the Los Angeles Times story, proponents of California’s plan to build new housing for the mentally ill homeless explicitly pledge allegiance to both strategies.

The new units would operate on a ‘housing first’ model, taking in homeless people with mental illness and drug and alcohol problems even if they refuse psychiatric or substance abuse treatment, officials said. The city and county of Los Angeles have been moving toward the model, which is endorsed by most experts and the federal government, but some funding still goes to housing with sobriety or treatment requirements, advocates said.

Remember deinstitutionalization? It was a really big “top down” idea that was fraught with unintended consequences. When the Times quotes former Senate President Pro Tem Darrell Steinberg saying, “The problem is getting worse everywhere. […] At the same time, we know what works,” the combination of strategic certainty and a crisis mentality should be a warning. Los Angeles could learn from the example of Phoenix, where a comprehensive, collaborative and data driven planning process is evolving. In the 1950s, before the era of deinstitutionalization, Yale professor Charles Lindblom counseled public policy makers to operate incrementally in a process he delightfully referred to as “muddling through.” Both the Housing First and Permanent Supportive Housing models have evolved out of real practice over decades in a wide variety of settings, but they are only just now being subjected to rigorous evaluation. A modest experiment like the Rochester property described in NPQ’s “Development Model Integrates Affordable Housing for People with Mental Illness” seems much more in sync with Professor Lindblom’s incrementalism.

Will these state-funded facilities strike the balance between treatment and control that meets the standard of protecting both the patient/tenant and the public in the least restrictive setting, as mandated by the Olmstead decision? As the public sector begins to write a new chapter in a half-century experiment with mental health and housing solutions, the balance between treatment and social control will continue to be a work in progress. Having evolved some strategies out of their practice, nonprofit providers and advocates have a new role: to set aside their interest in efficient service delivery in controlled settings in favor of their commitment to maximizing their clients’ autonomy in maintaining the balance between treatment and control.—Spencer Wells