On Tuesday, fifteen officials from the White House toured Skid Row in Los Angeles with the head of a local homeless shelter. “Four or five of them were from the Environmental Protection Agency,” Rev. Andy Bales of Union Mission church told me. “That’s because human waste flows into storm sewers.”
California is home to some of the world’s toughest environmental and public health laws, but skyrocketing homelessness has created an environmental and public health disaster. The 44,000 people living, eating, and defecating on the streets of L.A. have brought rats and medieval diseases including typhus. Garbage is everywhere. Experts fear the return of cholera and leprosy.
And homelessness is making people violent. “We are seeing behaviors from our guests that I’ve never seen in 33 years,” said Bales. “They are so bizarre and different that I don’t even feel right describing the behaviors. It’s extreme violence of an extreme sexual nature. I have been doing this for 33 years and never seen anything like it.”
Bales says he was one of the people who urged the US Government’s Federal Emergency Management Administration (FEMA) to intervene. “We’ve been crying out for a National Guard-like response,” said Bales, whose church provides food, showers, and shelter to 1,350 people camped nearby. In 2016 Bales lost the lower half of his leg to a flesh-eating bacteria from contamination on Skid Row.
How did things get so bad in California? The state has long prided itself on being humanistic and innovative. It is home to some of the world’s largest public health philanthropies, best hospitals, and most progressive policies on mental health and drug addiction. The Democrats have a supermajority. What went wrong?
According to Bales and other experts, California made homelessness worse by making perfect housing the enemy of good housing, by liberalizing drug laws, and by opposing mandatory treatment for mental illness and drug addiction.
Other states have done a better job despite spending less money. “This isn’t rocket science,” said John Snook, who runs the Treatment Advocacy Center, which advises states on mental health and homelessness policy around the country. “Arizona is a red state that doesn’t spend a ton on its services but is the best scenario in every aspect. World-class coordination with law enforcement. Strong oversight. They don’t let people fall apart and then return to jail in 30 days like California does.”
What happened in California isn’t the first time that we progressives let our idealism get the better of us. To understand how the current disaster unfolded, we have to go back in time, back to the post-World War II era when progressive reformers convinced themselves and others that they could destroy the country’s system for dealing with the mentally ill and replace it with a radically different and wholly unproven alternative.
A Mania for Reform
People considered the creation of state mental institutions in the 1800s to be a major progressive reform because they took the mentally ill out of prisons and hospitals and put them into a safer and kinder environment, notes the psychiatrist E. Fuller Torrey, M.D., in his devastating and critically-acclaimed 2014 history, American Psychosis: How the Federal Government Destroyed the Mental Illness System.
In many respects, the mental institutions were a step in the right direction, but by the middle of the 20th Century, their reputation was in tatters. They were understaffed and overcrowded. Some patients were poorly treated, even abused. Others were neglected. During World War II, Mennonites and Quakers worked in the institutions as an alternative to military service. After the war, they drew attention to the deplorable conditions.
Reformers felt they could do better. In 1945 they proposed community-based clinics not just to treat but also to prevent mental illness. They called for a federal takeover. Congressional advocates frequently invoked the US government’s Manhattan Project as inspiration. If America could build a nuclear bomb in a few years, why couldn’t we prevent and cure mental illness?
As Congress debated mental health reform in 1946, some were suspicious. “Men get strange ideas,” said Republican congressman Clarence J. Brown of Ohio. “They decide the only way in the world they are going to solve all the problems of mankind is to do a certain thing and that their field is the most important.” Many reformers believed mental illness was created by poverty and inequality and argued that solving it required creating “mentally healthy” environments, organizing tenants, and fighting landlords.
These reformers viewed mental illnesses like schizophrenia and bipolar disorder as socially constructed and not the result of biology, as most doctors believe today. They sought clinics that would “promote health” and “the development of a resilient character.” They wanted clinics to treat the “totality of [a patient’s] being in the totality of his relationships.” The psychiatrist played a special role, the reformers said. “One might even say,” wrote Francis Braceland, an influential psychiatrist who had studied with Carl Jung, “ the ideal goal of the psychiatrist is to achieve wisdom.”
The reformers were so confident in their convictions that they smashed the state mental institutions before creating an alternative. The reformers hyped new psychiatric drugs, which reduced the symptoms of schizophrenia, as a bridge to the new system. There was little resistance to the radical changes by existing mental institutions, whose leadership had been demoralized and discredited. And yet there was no evidence that community-based treatment would work. Between 1948 and 1962, the test that clinic reformers pointed to as the model had not prevented a single case of mental illness or treated a single individual with schizophrenia.
But attacking mental institutions had become hugely popular. In two hugely influential 1961 books, a psychiatrist argued that mental illnesses didn’t exist and a sociologist argued that the institutions themselves created mental illness. One year later, One Flew Over the Cuckoo’s Nest, a novel about a sane but socially maladjusted man who was drugged, electro-shocked, and lobotomized by a mental institution, became a best-seller. In 1967, the film “King of Hearts” depicted psychiatric inmates after World War II as living happily once freed from their asylum. In 1975, the year “One Flew Over the Cuckoo’s Nest” became a hit film, Michel Foucault argued in Discipline and Punish that mentally ill people had been better off in the Middle Ages when they could roam the streets without being shamed as deviant.
Over the next two decades, state mental hospitals would empty out. But the vast majority of released patients ended up homeless on the street. Congress had “encouraged the closing of state mental hospitals without any realistic plan regarding what would happen to the discharged patients,” notes Dr. Torrey, “especially those who refused to take medication they needed to remain well.”
And yet the reformers were becoming only more radical. “The changes I am talking about,” said a leader at the new National Institute of Mental Health, ” involves a redistribution of wealth and resources… society for the urban poor of such beauty and richness… nothing less than a privilege to be called poor.”
But when the community mental health clinics did start operating, they tended to treat the easiest-to-treat, not the hardest. It was a trend that worsened the longer the clinics were in existence. The clinic saw “very few individuals with serious mental illnesses,” reported a young psychiatrist working in Santa Monica near LA. “Instead, the patients were people from the community with various personal crises.”
In the end, no more than 5% of the federally-funded clinics “made any significant contributions to the care of patients being released from state mental hospitals,” finds Torrey. Financial abuses were rife, with clinics building tennis courts, swimming pools, and rooms for fads like “inhalation therapy” that did nothing for people with schizophrenia.
When critics faulted the clinics for their abuses, reformers defended themselves behind a wall of political correctness. One reformer-aligned task force that investigated the situation concluded in 1976 that “to criticize the [mental health] centers themselves for many (but not all) of their failings is to ‘blame the victim!’” The Carter Administration recommended making federal support permanent and included new money to prevent mental illness by reducing “societal stresses produced by racism, poverty, sexism, ageism, and urban blight.”
Republicans who had initially supported deinstitutionalization as a cost-savings measure became increasingly resentful of what they viewed as an anarchistic approach and sought to cut the budget for mental illness. But as federal support for the clinics declined, the state institutions were no longer in place to care for the homeless evicted to the streets. Everybody was in charge and nobody was in charge. The reformers grew depressed. “The deformed creature that has developed from the original community mental health center movement does not arouse much enthusiasm in any of us who had some more grandiose visions,” said one.
The problem, Torrey and other advocates for the mentally ill say, wasn’t de-institutionalization but rather the failure to provide new forms of treatment. “The majority of lives were little different than they had had while hospitalized,” he concludes, “and a significant number were considerably worse off.” Many didn’t even realize they were mentally ill, similar to some Alzheimer’s patients. For decades, radical reformers sought de-institutionalization in even the most extreme situations. In 1985, a public defender got a mentally ill client released from jail even though he had been found eating his feces.
Importantly, reformers never had evidence that community-based clinics would work better than big institutions. They just assumed it in a way that is eerily similar to the way that 1960s environmentalists in California, including Governor Jerry Brown, assumed “small-is-beautiful” policies would be better for the environment. Out of hubris, the reformers sought to smash the old institution before creating a new one. Intriguingly, that’s exactly what reformers would do again in California, 50 years later.
When Dogmatism Is Deadly
For decades, many progressives have claimed that homelessness is really just a kind of poverty, a manifestation of social inequality. In 1986, celebrity comedians Whoppi Goldberg, Robin Williams, and Billy Crystal held “Comic Relief,” a telethon for homelessness. Throughout it, they emphasized that the homeless were just like you and me, just poorer. Today, many of California’s leading homelessness advocates insist that the current crisis is due mostly to the housing shortage.
Homelessness experts and advocates disagree. “I’ve rarely seen a normal able-bodied able-minded non-drug-using homeless person who’s just down on their luck,” L.A. street doctor Susan Partovi told me. “Of the thousands of people I’ve worked with over 16 years, it’s like one or two people a year. And they’re the easiest to deal with.” Rev. Bales agrees. “One hundred percent of the people on the streets are mentally impacted, on drugs, or both,” he said.
Most of the time what people mean by the homelessness problem is really a drug problem and a mental illness problem. ”The problem is we don’t know if you’re psychotic or just on meth,” said Dr. Partovi. “And giving it up is very difficult. I worked in the local jail, and half of the inmates in the women’s jail were Latinas in their 20s, and all were in there for something related to meth.”
The people who work directly with the homeless say things worsened after California abandoned the “carrot and stick” approach toward treating the severely mentally ill and drug addicts who are repeat offenders. “The ACLU will come after me if I say the mentally ill need to be taken off the street,” said Dr. Partovi, “so let me be clear that they need to be taken care of, too.”
Bales says things worsened ten years ago when L.A. and other California cities rejected drug recovery (treatment) as a condition of housing. “When the ‘Housing First’ with a harm reduction model people came in they said ‘Recovery doesn’t work,’” said Bales. “But it was after that when homelessness exploded exponentially.”
Bales says people have little incentive to do treatment when there is no threat of jail time. “[The Housing First harm reduction advocates] talked about new services, but they were all voluntary.” Things went further in this direction with the passage of Proposition 47 in 2016, which decriminalized hard drugs and released nonviolent offenders from prison without providing after-care support. “Our guests went from 12 – 17% addicted to 50% or higher,” Bales says. “Policymakers need to understand that if you allow the use, you also allow the sales, and if you allow the sales, then you allow the big guys to break your legs when you owe them money,” says Bales.
Snook says that California is so unwilling to require non-voluntary mental health care that it is only now considering more extensive “conservatorship” — where a health official is given the authority to make decisions for a mentally incapacitated individual — and only after nine acts of violence against themselves or others.
“Imagine having a sick child and hoping he attacks someone once a month so somebody can do something!” said Snook. “That is so out of sync with the rest of the country, and with what mental health care looks like, that it is laughable.”
Lack of shelter and leadership are factors alongside extreme progressive idealism. “It’s the impact of not having a stick and not having shelter,” says Bales. Snook agrees. “There’s a provision that says Medicaid will now pay for beds in psychiatric hospitals,” said Snook. “It’s a no-brainer, but California is hemming and hawing. They don’t want to involuntarily incarcerate, but it’s self-defeating because you end up with mentally ill in jail because a bed isn’t available.”
Is the problem a lack of money? “California spends more than most places,” said Snook, whose organization researches and advocates solutions for mentally ill homeless people nationally. What happened to the money from Proposition 63, the successful 2016 ballot initiative that taxed millionaires for mental health? “A Hoover Foundation audit found funds that were supposed to go to seriously mentally ill were used for yoga and trauma and other laudable things, but none for the seriously mentally ill,” said Snook.
“When you look at the amount of money being spent, and then you hear the argument that we need more money? You have to ask, ‘How much more?’” said Snook. “Right now it’s just good money after bad. There’s no oversight and no accountability.”
Liberal idealism also wasted much of the $1.2 billion that L.A. voters raised in 2016 when they voted to tax themselves to build housing for the homeless. “It was supposed to build 10,000 units but in truth will create half that because each one costs $527,000 to $700,000,” said Bales. “They will take ten years to build, at which point 44,000 lives will have been destroyed by living on the street.”
Why did progressive housing activists in L.A. insist on building such expensive apartments for so few people, so slowly, rather than quickly building cheaper units faster for 44,000 people?
“[Housing First] is a dogmatic philosophy,” said Bales. “I’ve lost friends. One of my closest friends is attacking me for pushing for housing that costs $11,000 instead of $527,000 per person. He can’t get that we can’t provide a $527,000 to $700,000 apartment for each person on the street. I’ve been in planning meetings where people said, ‘Everybody deserves a granite countertop,’ but that isn’t going to work for 44,000 people.”
L.A.’s woke housing advocates have intimidated the city’s mayor. “I think the mayor’s unwilling to put out bridge shelters because of backlash from some homeless advocates,” said Bales, “and is concerned about NIMBYs, and may be concerned about union workers because the shelters may not be built by the unions.”
Beyond Right and Left
Despite the emergency, and in some ways because of it, homeless reformers are hopeful today that California will seek a more moderate path toward treating mental illness and drug addiction and providing shelter. “The problem is so bad and so significant that there’s an opportunity now,” said Snook.
Bales agrees. “In New York where they put a roof over the heads of 95% of the homeless, it took a law to change things,” he said. “I thought it would take a law here, too, but maybe we can get there without a law if people continue to show political courage.”
California recently awarded L.A. $124 million for the homelessness emergency, of which L.A.’s mayor has spent $66 million on 27 cheap, quick-to-assemble temporary shelters that can quickly get 13,000 people off the street. “I think the mayor has been fighting an uphill battle against the powers that be, and his political courage is growing,” said Bales.
One sign of trouble was the resistance by some in California to receiving help from the federal government. “[Trump’s] budget has proposed slashing public housing … and eliminating community development block grant dollars,” LA’s mayor said. “It’s totally out of step with the idea that he’s here to help.”
But others were more conciliatory “I am wary of any such offer from an administration that consistently demonizes vulnerable people,” the governor’s top homelessness advisor, Sacramento Mayor Darrell Steinberg, told me “And yet, if the federal government wants to offer resources to help bring people indoors and to offer federal facilities to shelter and house people, we should readily listen. We cannot afford to politicize an issue which needs real thought and real commitment.”
Everyone I spoke to hopes that the current crisis makes all sides less dogmatic. Something like that happened at the federal level after a mentally ill man killed 20 elementary school children in 2012. Democrats and Republicans found common ground on sweeping mental health reform legislation in 2015. “It wasn’t a Democrat or Republican thing,” says Snook.
Steinberg, for his part, would like to see legislation codifying his “right/obligation to shelter” framework, which blends the traditional liberal emphasis on rights and care with the traditional conservative emphasis on order. “I’m open to more carrots and sticks and would be for an obligation to seek shelter. I don’t think living outside is a civil right,” he told me. “We back, philosophically, ‘Housing First’… but if all we did was permanent housing, it would be until 2037 before we housed every person on the streets in the Bay Area.”
It’s hard to see any of what needs to happen as particularly partisan. “The key is focusing services on the seriously ill,” argues Snook. “You provide extended care. You open up beds for when they are stable. You provide care to people to stay out of the system.” What about the homeless who are not mentally ill? Focus on the hardest population first, he urged. “Once you get that population addressed, you can move on to the others. This is what New York City did. Once you get that population serviced, you’re not in crisis mode anymore, and you free up money for everyone else.”
I left the reporting for this column surprised by how stuck California’s leaders remain in 1960s ideology and how slow they’ve been to react to the crisis. “It’s better late than never, but still we are not treating it in the urgent manner we should,” said Bales. “We’re not there yet where people are really taking it seriously as an emergen