A major mental health crisis is severely impacting unhoused people living in cities across the United Sates, the U.S. Conference of Mayors said at its annual meeting in June.
The next month, a bipartisan delegation from the conference met with senior congressional leaders of both parties, calling the mental health crisis “America’s No. 1 problem” and articulating the need for federal legislation.
Despite the many recent improvements to Santa Barbara County’s behavioral wellness system, the mental health crisis is evident in our community.
How did we get here?
Two public health emergencies — the COVID-19 pandemic and the opioid overdose epidemic — have collided with two negative social trends — California’s housing and mental health care crises — to greatly impact a marginalized population that wasn’t doing that well psychologically even in the best of times.
The Conference of Mayors report listed the major problems as:
- Substance use disorders
- Homelessness stemming from mental illness
- Mental and behavioral health worker shortages
- Lack of access to behavioral health services
Other symptoms of this mental health crisis include elevated rates of depression and suicide, increased acts of violence (including self-harm, interpersonal and domestic violence), and increased substance use leading to marked increase in overdoses, particularly opiates such as fentanyl.
In ordinary times, the mental health of the unhoused is broadly marked by a mass psychology of despair, in which stress, loneliness, depression, anxiety and boredom are pervasive.
In my many interviews with people living on the streets of Santa Barbara and in our shelters, I find a population worn down by months and months of endless suffering.
Typical complaints include being depressed because of life circumstances, traumatized by early childhood experiences, being cut off from the support of family and former friends, constantly having to move your camp, getting your bike stolen yet again, receiving tickets for illegal camping, losing friends to fentanyl overdoses, running out of food stamps (EBT cards) after three weeks, and being mistreated by law enforcement officers.
There is only so much that one can take — even the cheeriest and most optimistic person!
This population typically includes many people who receive no treatment in spite of having severe and chronic mental distress. Rates of anxiety and depression are typically higher than the general population.
A full 80% of people on the streets have experienced traumas that negatively impact their lives.
Self-medication for these symptoms (aka drug abuse) is common and people have easy access to drugs and alcohol. Peer acceptance of this is normal.
Even in the best of times this is a population barely holding on.
Our Housing Crisis
There are 172,000 people unhoused in California, the largest homeless population of any state and 30% of the nation’s total, even though California has 12% of the U.S. population.
Many of these people need affordable housing with supportive services.
Many others — 1 in 5 living in California — spend more than 50% of their paychecks on rent and therefore are at risk of losing their housing.
The medium home price is $859,800 — 2½ times higher than the median national home price.
In my research, I have learned that being poor does not make people homeless but being very poor where housing is unaffordable does.
Gov. Gavin Newsom has made housing and homelessness a top priority of his administration, investing $22 billion with a plan to create 88,000 new affordable homes, including more than 44,000 new housing units and treatment facilities for the homeless.
Mental Health Crisis
An estimated 1 in 6 adult residents of California live with mental illness. The state has long struggled with funding for the care of the most severely ill patients at state psychiatric hospitals.
Proposition 63, the Mental Health Service Act, was approved by voters in 2004 and levies an additional tax on those with an income of more than $1 million. Today, services vary from county to county and no uniform standard exists.
Unable to find adequate care many people end up in jails or prisons, or become homeless.
In recent years the largest psychiatric institutions in many California counties, including Santa Barbara County, is the local jail. Our jail often houses up to 200 people with mental illness.
More Californians with mental illness are behind bars than in hospital beds. More than 30% of California prisoners currently receive treatment for a serious mental disorder, a 150% increase in nearly two decades.
It is estimated that 1 in 3 unhoused persons in California has mental health challenges.
California lags behind the rest of the country in providing community treatment, with 37% of adults receiving services compared to a national average of 43%.
California has a shortage of mental health providers, leading to long wait times and long travel distances for those seeking treatment.
Substance Use
Homelessness and substance use go hand in hand. The National Coalition for the Homeless found 38% of homeless are alcohol-dependent, while 26% are dependent on other substances.
To understand this substance use among people experiencing homelessness, there are a few things you need to know.
Some in this social world are countercultural in that they have norms and values that are oppositional to mainstream and middle-class attitudes. For those living on the streets, substance use is common, largely accepted and readily available.
Moreover, as stated above, trauma is ubiquitous among unhoused people. I have learned that childhood traumas, including those from sexual abuse, physical and emotional abuse, and neglect are central pathways into homelessness.
And that trauma begets attempts to self-medicate the accompanying pains and sorrow with legal and illegal substances.
In his pioneering book, In the Realm of Hungry Ghosts, psychiatrist Gabor Maté interviewed the addicts of Vancouver’s Skid Row, finding that most suffering with substance use disorders are trying to relieve deep pains caused by childhood traumas.
The opioid epidemic, which is in full force across the country, is having a devastating effect on the unhoused population.
According to a report to the county Board of Supervisors in June, the number of people experiencing homelessness who died nearly doubled in the two years most recently tabulated. While 85 died in 2017-2018, the total was 143 in 2019-2020.
The average age of these deaths is 54, which is 22 years less than that of housed people in the county.
Fentanyl accounted for 1 in 5 deaths among California young people ages 15 to 24 in 2021.
The mental health crisis among people experiencing homelessness is clearly a complex problem for which there are no easy solutions.
For people with severe mental health challenges, housing is a prerequisite for getting better.
Elsewhere I have called for a “Marshall Plan” to build a substantial amount of affordable housing in Santa Barbara County, arguing that this upfront investment in our community will actually save a lot of money.
But housing in and of itself will not eliminate this crisis. We need to invest in our county’s behavioral wellness system, funding more of the evidence-based practices that have already proven successful for preventing opioid overdoses, such as targeted Nalaxone distribution, harm reduction and medication assisted treatment.