On California ballot: Housing鈥檚 role in addressing mental illness
| Los Angeles
A soft knock on her office door interrupts Olga Recendez, the administrator of a group home for adults with severe mental illness. She rises from her desk and opens the door to find a resident holding artwork: It鈥檚 an outline of a cat, loosely colored in with hot-pink marker and dotted with hand-drawn flowers.
Ms. Recendez praises the artist and clips the piece to a collection of similar treasures on a whiteboard. The resident, a willowy woman diagnosed with schizophrenia, also has a question. Will they do something special for her birthday? 鈥淵es,鈥� Ms. Recendez reassures the woman, not named for privacy reasons. 鈥淵ou are special.鈥� The resident seems pleased, and the administrator gently closes the door.聽
鈥淭hese are the few things that make a difference,鈥� says Ms. Recendez, who works here at the ASC Treatment Group, a privately owned facility for 37 adults in a Los Angeles residential neighborhood. 鈥淵ou just need that one-on-one.鈥� It鈥檚 one of the reasons the client has succeeded in living here for more than a year 鈥� remarkable, given her history of psychiatric hospitals, failed community placements, and urge to run away. Absent this supportive environment, she could 鈥渧ery, very easily鈥� become homeless, says Ms. Recendez.
Why We Wrote This
As states face rising homelessness and mental illness, Californians are seeking solutions. They will soon vote on Proposition 1, which would help people get off the streets and into homes and places for treatment.
As states across America grapple with the twin challenges of rising homelessness and mental illness, California鈥檚 counties are clamoring for more places like ASC. But there aren鈥檛 enough of them. Neither is there enough affordable housing in this expensive state. Despite billions spent in recent years, homelessness has increased, and many unhoused people struggle with mental illness and addiction. All of this has rolled into a perfect storm impacting public health and safety, businesses, and quality of life 鈥� making homelessness a top concern for California voters.
Politicians, not surprisingly, are under tremendous pressure to do something. Their latest effort, , which will be on the March 5 ballot, would overhaul the state鈥檚 mental health system to firmly link it to housing. For the first time, counties would be required to spend behavioral health dollars on housing for homeless people with mental illness and addictions. Proposition 1 also includes a $6.4 billion state bond to secure supportive housing and treatment places for homeless people, with $1 billion for veterans. Gov. Gavin Newsom dubs it 鈥渢reatment, not tents.鈥�
The measure has its critics. One main objection is that more county behavioral health dollars for housing means fewer for mental health services. While the ballot measure promises more than 11,000 places for treatment and living, the independent state legislative analyst says the new measure would reduce statewide homelessness 鈥渂y only a small amount.鈥� Yet the legislation behind the measure passed with near unanimity in Sacramento last year.聽 shows nearly two-thirds of likely voters support it.
鈥淚n a perfect world, you wouldn鈥檛 be robbing Peter to pay Paul,鈥� says Dr. Margot Kushel, director of the Benioff Homelessness and Housing Initiative at the University of California, San Francisco. But given funding constraints, 鈥渨e really don鈥檛 live in a perfect world.鈥澛犅�
This is not a new problem for California. Homelessness in the Golden State is by far the highest in the nation, in 2022. That鈥檚 a third of the total national count and far outpaces second-place New York. Last year, the Benioff initiative conducted the study of homelessness ever undertaken in California. Two-thirds of participants reported symptoms of current mental health challenges. Only 18% had recently received nonemergency mental health treatment. One in 5 who used drugs or alcohol said they wanted treatment 鈥� but couldn鈥檛 get it.
Even if the ballot measure won鈥檛 reach as many people as need help, Dr. Kushel says its significance lies in the marrying of mental health with housing. 鈥淭here is no medication as powerful as housing,鈥� she says. 鈥淭here is no amount of fancy health care that I can provide for someone that can really do much if they are still homeless.鈥�
Consequences of closing state hospitals
The nation, including California, is still grappling with the seismic mental health shift of the 1960s 鈥� the closing of America鈥檚 ill-famed state psychiatric hospitals. No one wants to go back to the asylums that warehoused patients in locked wards, often for decades. The 1975 film 鈥淥ne Flew Over the Cuckoo鈥檚 Nest鈥� dramatized this hidden world, ending with the main character鈥檚 tragic lobotomy. The film swept the Oscars.
President John F. Kennedy tried to create a landing place for the newly discharged patients by setting up community mental health centers in the early 1960s. By 1977, nearly 400,000 state hospital beds had disappeared. But only 5% of those discharged patients were reappearing in the new local mental health centers, which mostly handled less acute cases, according to 鈥淗ealing: Our Path From Mental Illness to Mental Health,鈥� a book by Dr. Thomas Insel, former director of the National Institute of Mental Health.聽
At the same time, the Vietnam War sent home veterans who were struggling with post-traumatic stress disorder and addictions, left to fend for themselves. 鈥淎 whole range of things came together, and that really was the beginning of the homelessness epidemic,鈥� says Dr. Insel in an interview.聽
Compounding this, in 1982 President Ronald Reagan sent federal funding for mental health community centers back to the states as block grants. Many states had other priorities and pressures. They focused instead on building prisons and jails, which have become de facto mental health institutions.
鈥淚t鈥檚 an absolute disaster for people with these illnesses,鈥� says Dr. Insel about those who end up in jail. Proposition 1, he says, tries to undo some of this history and help 鈥渢his very neglected part of the population who has always had a very treatable illness.鈥澛�
Housing and care together
Stephanie Klasky-Gamer is giving a tour of The Fiesta, an apartment building in North Hollywood designed for those who are chronically homeless with severe and persistent mental illness.
It鈥檚 run by her nonprofit, , and is the type of housing that could be covered by Proposition 1, if it passes. Known as permanent supportive housing, it鈥檚 independent living, with supportive services for those who want them.
Stepping out of the elevator, Ms. Klasky-Gamer greets a resident, Joseph. Seven years ago, he was living under a freeway overpass. This afternoon, he鈥檚 carrying two new king-size pillows up to the studio apartment that he has called home since The Fiesta opened in January 2017.
This is how you measure success, says Ms. Klasky-Gamer, president and CEO of LA Family Housing: 鈥淭hat he is stable. That he is able to go out and buy two new pillows for his bed, because literally he came in with nothing.鈥澛�
She remembers the initial move-in day for residents. 鈥淚t was pouring out,鈥� she recalls, 鈥渁nd people came in with trash bags, dragging their belongings. That he鈥檚 here seven years later, looking healthy, able to use his fixed income to take care of himself 鈥� that鈥檚 pretty good.鈥�
What鈥檚 made the difference, she explains, is having housing and services in the same place. The nonprofit owns and operates more than 30 properties across the county 鈥� from converted hotels to new buildings. That integration model is showcased here at its headquarters, a contemporary campus designed by Ms. Klasky-Gamer, alongside an architect.聽
Tall glass windows let in shafts of natural light. Courtyards and planters invite socializing 鈥� or relaxing. The campus features a health center, dental clinic, on-site case management, and spaces where visiting professionals can offer services like legal advice and employment help.
Families and adults transitioning from homelessness live in interim residences on one end of the campus. The Fiesta, with its 49 studio units, is on the other end. Each apartment floor has its own case manager, located across from elevators and near mailboxes so that counselor-resident interaction is a daily routine. That鈥檚 important because accessing services is voluntary.
Ms. Klasky-Gamer backs Proposition 1 because of the need for capital investment in housing after decades of slow-growth policy in Los Angeles. In 2022, homelessness in Los Angeles County reached , up 9% from the year before.
鈥淲ithout the housing itself, we will make no dent in ending homelessness,鈥� she says.
Moneys from Proposition 1 can鈥檛 come soon enough for LA Family Housing. Her organization has 750 permanent supportive housing units in the pipeline. Without those, she says, people moving up from interim housing have nowhere to go.
Proposition 1 side effects
Proposition 1 takes up 68 pages in the voter guide. Not exactly an easy read. It would overhaul a law that voters passed two decades ago when they approved a 鈥渕illionaires tax鈥� for mental health services. It was considered revolutionary at the time and raises $2 billion to $3.5 billion each year.聽
Proposition 1 would change that setup in key ways. It adds substance abuse to the ills covered by the tax. It directs a small slice of the tax to training mental health workers, of whom there is a huge shortage. And it requires county mental health departments, which get most of the tax revenue, to divert 30% of those funds to housing that runs the gamut, from group homes, to motel conversions, to secure facilities.
But there is pushback. A group called argues that diverting a third of the tax dollars to housing would hinder current, effective mental health services 鈥� like early prevention, outpatient treatment, and crisis intervention.
In San Diego County, for instance, the millionaires tax supports a network of crisis stabilization units 鈥� alternatives to emergency departments. Staffed with mental health professionals and peer supporters, they help people access care closer to families and support services, explains Luke Bergmann, director of the county鈥檚 Behavioral Health Services.
The stabilization units 鈥渉ave had some pretty dramatic impacts on access to care,鈥� says Dr. Bergmann. If he loses those funds, he asks, 鈥渨here will I find money for this core behavioral health care service?鈥�
While he welcomes Proposition 1鈥檚 emphasis on infrastructure, he says it鈥檚 asking counties to do more with less. A silver lining, he hopes, would be if this forces a discussion about how to fully integrate behavioral health care with general health care, instead of having it siloed off with special funds and programs as in Proposition 1.
Supporters acknowledge the funding trade-off, but they say the focus must shift to housing. 鈥淭he nature of our mental health crisis and homelessness have changed a lot over the last two decades,鈥� says Anthony York, a spokesperson for the . 鈥淲e have to be able to prioritize.鈥�
Critics target another issue: locked facilities and forced care. California now has only one-sixth of the psychiatric hospital beds it had in the 1950s, which is not enough for some mental health advocates. But others oppose Proposition 1鈥檚 provision for more locked settings.聽
鈥淚t鈥檚 really hiding the problem, not solving the problem,鈥� says Paul Simmons, one opposition campaign leader.
In recent years, the state has also broadened the legal framework for conservatorship, which allows a judge to appoint a decision-maker for those who can鈥檛 manage alone. Civil rights advocates and others have fought this trend, arguing that forced treatment violates a person鈥檚 liberties and can make conditions worse.
Alex Barnard, author of the book 鈥淐onservatorship:聽Inside California鈥檚 System of Coercion and Care for Mental Illness,鈥� sees Proposition 1 as a harbinger of a nationwide shift toward more restrictive, high-level mental health settings. He notes New York鈥檚 nearly $1 million fine聽 last year for failing to bring dozens of psychiatric beds back online after the pandemic.
鈥淵ou鈥檒l hear inflated or exaggerated claims that we鈥檙e going back to the mass institutionalization of the 1950s,鈥� says Mr. Barnard, an assistant professor of sociology at New York University. 鈥淏ut I don鈥檛 think that鈥檚 happening.鈥�
The Proposition 1 campaign says the emphasis on locked facilities is misplaced and expects that much of the new housing will be聽built for higher-functioning people.聽
An investment that paid off
Back at the residential facility in East Los Angeles, ASC executive director Michael Rosberg questions how wisely those Proposition 1 dollars would be spent. Too often, he says, housing is built to work for staff, not those they serve. Like Ms. Klasky-Gamer, he鈥檚 a believer in human-centered design as a way to improve mental health outcomes. He鈥檚 applying those concepts in a completely different setting that could also be covered by Proposition 1.
ASC runs two treatment residences, as well as an outpatient clinic. But unlike The Fiesta, these are communal living, two-to-a-room, with 24-hour board and care in what鈥檚 called adult residential facilities. ASC鈥檚 clients typically come from acute and locked settings. Most are indigent, on disability. They stay for about 16 months to stabilize and then move to more independent arrangements with wraparound services 鈥� places like The Fiesta. Sometimes they return to family.聽
On a bright winter day in January, Dr. Rosberg is at the ASC site in Los Angeles, mingling with a few residents on recently landscaped grounds. The peaceful setting, with snowcapped mountains as backdrop, is an investment that has paid off in dramatically improved client behavior.
With a government grant that helped replace turf with drought-resistant landscaping, ASC has transformed its 2-acre site from a patchy, grassy area that people didn鈥檛 use to one of healthy ground cover and intersecting gravel paths that lead to social spaces. Benches, a pergola, and a vegetable garden allow for togetherness, while a big tree at the property鈥檚 edge provides a private haven where one client rests. It鈥檚 his favorite spot.
鈥淲e wanted it to be wonderful for the people who live here,鈥� says Dr. Rosberg, a licensed psychologist. 鈥淲hat we didn鈥檛 expect was that our clients improved dramatically.鈥�
He ticks off the results: a 70% reduction in substance abuse聽(even though residents are free to go into the community, where drugs and alcohol are聽easily available); a 34% drop in use of emergency medicines for psychiatric crises; a 70% decrease in the number of people who have run away; a 54% reduction in crisis-driven, staff interventions.聽
An added benefit is that families of the residents want to visit them on campus. They bring lunch and hang out, instead of whisking their relative away to a noisy restaurant.
ASC changed nothing else 鈥� not the staffing, not the daily meal and snack routine, not the morning meds and therapy, not the activities and small jobs. And聽not the kindness and acceptance.聽
鈥淭he implications for environmental therapy as a component of聽service are very significant,鈥� says Dr. Rosberg. Especially for clients who聽are treatment-resistant, as is the case at the ASC facility, 鈥渋t could have a聽profound effect on the use of resources.鈥�
