A Commonsense Approach to Addressing Homelessness

By Erinn Broadus

Homelessness a national concern

The increase in homelessness and responses to it have been of growing concern in cities throughout the nation. Here in Louisville, Metro Government spent $89 million last year to create a homeless “village” consisting of weather-proof tents for homeless residents. Even more has been spent in larger cities—$360 million in San Francisco and $600 million in Los Angeles—yet homelessness has only increased. In Louisville, homelessness has increased by over 40% over the past three years, from 7,572 people in 2018 to 10,640 in 2021. More alarming, the number of people sleeping on the streets has increased—from just 1% of the homeless population in 2018 to 35% in 2021. This is cause for concern.

According to a 2020 evaluation of the Homeless Initiative Grant in Louisville, the “average” person served in FY 20 was a white male with no income, a physical and mental condition, and a chronic health condition. Of the more than 3,000 individuals served in 2020, 25% had drug or alcohol problems (or both), and 26% had mental health problems. Collectively, that’s over half of the homeless population with chronic unmet needs.

Louisville is not the only city to see an influx of people living on the street with chronic health issues. In a 2019 survey of more than 64,000 homeless individuals from 15 states, California Policy Lab found that 75% of unsheltered homeless had substance abuse issues. 78% had mental health conditions, and 50% had substance abuse, mental health, and physical health conditions.

Figure 1: Physical health, mental health, substance abuse, and trimorbidity by shelter status

The cohort of homeless living outdoors is usually the most erratic because they refuse or do not have access to the psychiatric help they need. In fact, substance use and unmet mental health needs are significant contributing factors differentiating unsheltered homeless from their sheltered (be it in emergency shelters, cars, or government-assisted housing) counterparts. When asked about the main factors that lead to homelessness, unsheltered individuals were three times as likely to report mental health conditions (50% compared to 17%) and eight times as likely to report drug use (51% compared to 6%) than those with some sort of shelter. The fact that those with the most pressing behavioral needs are the ones most public facing has created a disconnect between societal expectations of decency and what has been allowed to thrive. Stories of the consequences of this abound.

In January, a New York woman was pushed in front of a moving train to her death by a homeless man with a history of violence. He had previously been declared unfit to stand trial following a psychiatric evaluation. A homeless man in Queens attacked a woman with a hammer the next month, fracturing her skull. Similarly, in Seattle, a woman was knocked unconscious with a baseball bat. Other stories, such as the woman attacked with a bag of human feces while waiting for the bus, indicate that addressing this subset of homelessness requires more than just affordable housing.

It is not surprising that this group is often characterized by mental instability and needs substantially more services than those simply in poverty. The increase in homelessness as defined by living outdoors can be directly attributed, at least in part, to the elimination of psych wards in the 1950s. Because of abuses within the institution and hopes of a better system, the patient population in psychiatric institutions decreased from over one million in 1970 to about 100,000 today. Many of those who would have benefited from long-term psychiatric care find themselves on the street, in jail, or both.

While those living outdoors with mental health issues do not constitute the majority of those experiencing homelessness, they are precisely the group wreaking havoc on our public spaces. If we want to reclaim our cities, we cannot do so by simply waiting for them to change their mind. When your choices are determined, or at least heavily influenced, by mental instability and drug addiction, it is not reasonable to expect rational decision-making.

Reducing unsheltered homeless

Addressing this issue will require several agencies to collaborate, from mental health professionals to the police. Many times, those with extreme mental disabilities are not capable of entering treatment or accessing stabilizing treatments independently.

Forced treatment, or civil commitment, is one step cities and states can take to provide the treatment necessary for those extreme cases of homelessness. The legality of this option differs from state to state, but usually when an individual is a danger to themself or others, they qualify for involuntary treatment to get stabilized. To address the unmet needs of those requiring psychiatric stays, the Federal Department of Health issued a waiver on the limits previously placed on Medicaid funds for long-term psychiatric care. Despite this, no states have accepted and implemented the expansion of funding for these purposes.

Similar approaches include outpatient commitment and conservatorships. In 1999, Andrew Goldstein, a man inflicted by his personal demons, pushed Kendra Webdale in front of a moving train. Prior to that day, he had attacked at least 13 other people and several individuals at the hospital he found himself in. Despite a pattern of aggression, Goldstein was continuously released from psychiatric care and put back into the public. Because of him and the inability of the state to subdue him or protect the public from his violent tendencies, Kendra’s Law was enacted in New York to authorize courts to force mentally ill individuals with a problematic history—such as incarceration or violence—into treatment plans. From 1999 to 2019, homelessness of those committed under Kendra’s Law decreased from 28% to 12% (before entering the program compared to while in the program). Additionally, incarceration of those in the program declined from 28% to 8%. Despite these successes, it has been sparingly used.

Kentucky has an option for involuntary commitment that a family member or friend can invoke called “Casey’s Law.” In 2021, 1,391 verified petitions were received by the Administrative Office of the Courts. Yet, of those, only 492 judgments of involuntary treatment were given.

While Casey’s Law is geared towards family members with drug problems, the gap in petitions for treatment and granted orders indicates that involuntary treatment is a service that Kentuckians want but do not have full access to.

In 2017, Kentucky passed a similar measure but focused on unmet mental health needs that are severe enough to likely put the person in jail or the hospital without intervention. It was named “Tim’s Law” after Tim Mortan, a schizophrenic man who was hospitalized more than 40 times, died due to neglected health problems. It has only been used once since its passing. Despite the effectiveness and need for involuntary options such as outpatient treatment, it is widely underutilized.

Involuntary treatment has worked even for those who don’t want the services. Drug courts have proved influential for individuals who haven’t hit “rock bottom” and have no intention of seeking help for themselves. Gaining clarity through sobriety in jail and access to resources have proved transformative for many people. As such, the police should be a tool utilized to ensure that those committing crimes are addressed and no longer pose a danger to themselves or the public. A review of drug court effectiveness by the Office of National Drug Control Policy found that drug courts reduce crime by 8 to 35 percent, depending on how they are administered.

Whether selling or using drugs, urinating in public, or assault, breaking the law should be penalized and addressed. By looking the other way at illegal acts within the confines of a homeless camp, one effectively condones and encourages that behavior. In San Francisco, leadership has taken a “hands off” approach to low-level drug use and dealing, and the situation has become dire. Used needles, trash, drug use, and overdoses have taken over in certain areas, effectively kicking the public out in favor of outright criminality. In some cities, drug users and dealers can be seen openly using and dealing drugs without consequence. Homeless deaths in San Francisco doubled from March of 2020 to March of 2021—primarily because of drug overdoses. While Covid certainly contributed to the increase in overdoses for both the homeless and the public alike, San Francisco’s unwillingness to address lawlessness has proved lethal.

Creating a safe, cohesive community for residents requires upholding the law at a bare minimum. After arrest, resources should be available to treat whatever ailments have yielded that behavior. This includes access to necessary medications while incarcerated and after release and treatment/aftercare plans that hold individuals accountable.

Expanding shelters can be effective, especially in the short term, but it cannot be the only solution. The most prominent low-barrier shelter (meaning there are few rules that individuals need to follow to stay there) is Wayside Christian Mission, which operated at 102% at the last measure. A detailed analysis from the University of Louisville found that several people chose to sleep on the street despite open beds at emergency shelters—citing dangerous living conditions within the confines of the walls.

Resolving the problem of unsheltered homeless is going to take an expectation of accountability. Not only from those currently in that living situation, but also city leadership. The police are only as useful as the courts who decide what to do with the offender. And the courts are only as useful as the services they can provide—be it long-term or not. By expanding treatment options and emergency shelters and returning to a rule of law that holds all members of society accountable for their transgressions, the public can begin to reclaim their outdoor spaces. Not only that, but the chronically homeless can begin to reclaim their lives.