Hope for Sacramento

Homeless is a broad term, but it is the one we have. There are roughly 4 groups of people who make up the Homeless population in Sacramento:

·  Economic. Someone who has lost a job, recently been divorced, is a student, or just lost too much money at a Casino, these are people who don’t have a place to live, but are the easiest to help back into the mainstream of society, and typically present the fewest issues.

·  Mentally Ill. People with untreated schizophrenia, bipolar, depressive, and other serious disorders. In times past these people would have been subject to involuntary commitment, but with the closure of the state mental hospital system they are now on the street.

·  Substance abusers. Previously the drug of choice was alcohol, but increasingly the drugs being used are intravenous consumption of meth and heroin.

·  Campers. People who, for whatever reason, have no desire to live in a permanent structure, hold a job, or lead a traditional life.

These 4 groups are not exclusive: the mentally ill for example are also often addicted to heroin or meth. Also, while all four drivers may be present in our community, they are not all of equal impact. These “chronic homeless” are the people that are both the hardest to treat and the disproportionate source of societal ills ranging from fecal matter in the streets, to petty theft, to hypodermic syringes on the sidewalk. To simplify, when referring to Homeless in this document we are referring to the chronic population who are mentally ill, addicted, or (usually) both.

Background items on the Homeless issue.

• Martin v. Boise. The Federal 9th Circuit Court of Appeals held that enforcing a “No Camping Ordinance" on public land is unconstitutional unless there are beds available at a shelter. Since Sacramento has insufficient bed space, enforcement of the No Camping ordinance has been suspended. 
• "Housing First" policies. “Housing First” is a controversial theory that holds that the key to getting change is to first house the homeless without first addressing Mental Health or Addiction issues. The result of this concept is the “Low Barrier” Shelter, also known as a “Wet Shelter”.
• Faith based group exclusion policies. For decades (or even longer), many of the groups that serve the Homeless have been faith based groups like the Salvation Army. However, because these groups are religious in nature they are now coming into conflict with the political and ideology based policies of the City. For example, all of the officers that run the Salvation Army are actually ordained ministers of a Christian denomination that is an offshoot of Methodism. Since their theology does not accept that practicing homosexuals can be ordained as ministers, the City terminated all contracts with the Salvation Army for serving the Homeless, even though they do so at an extremely low cost to taxpayers. As a result, a 125 bed facility now stands empty, despite a claim of a critical lack of beds by City of Sacramento officials.

City of Sacramento Plan

• “Scattered Shelter”. Multiple small locations throughout the City instead of one or more larger/centralized facilities.  
• Low Barrier Shelter. In these facilities you can come in with severe and unaddressed mental health issues without a requirement to seek treatment. Far from requiring a commitment to sobriety, you can come in high, and even bring your drugs with you, although you are prohibited from openly using drugs in the facility.
• Selective Protection. In March 2019 the City passed an ordinance prohibiting daytime camping, but they only applied it to immediate area around City Hall.
• Non-Prosecution of Drug laws. The 

Criticisms of City approach

• Inappropriate locations. As discussed, the CHP estimates that 90% of the chronic homeless are addicted to either meth or heroin, and data from the Railroad Ave facility shows that more than half also have severe Mental Health issues as well. By any rational definition, a hugely disproportionate number of people in this state are a danger to themselves and others. The City’s plan thus proposes placing people who are a danger to themselves and others
  • Across the street from a daycare facility/Playground
  • Next door to a tutoring facility
  • Sacramento sports facility
  • 2 blocks from a Billion dollar plus sports and entertainment facility
  • 1 block from the State Capitol (anyone remember Squeaky Fromme?)

Commentary. The issue is not whether or not our community needs shelter beds for the chronic homeless population, we do. However, just because we need shelter capacity for people in this condition does not mean that we need it in these locations. 

There are many structures and facilities that we need for the proper operation of our society, but that are also inherently hazardous in some way. The normal way that we have dealt with the “needed but hazardous” category has been to place these facilities in appropriate locations. For example, we need gasoline storage facilities to enable our economy to work, but because they are a hazard we will not place them across the street from a child-care center. Even Cannabis cultivation, which occurs within massively secured facilities, is deemed by the City zoning code to be so dangerous that it is restricted to areas already zoned for Industrial or Heavy Commercial activities, and cannot be placed near playgrounds, day-care facilities, etc. Compare this to the City’s plan for Low Barrier facilities where a lack of zoning allows the proposed shelters to be placed across the street from a daycare facility, next door to a children’s tutoring facility, 2 blocks from our most prominent entertainment facility, etc.

• “Tidal flow”. The rules for Low Barrier shelters state that the residents can be high, and can have drugs on them, but they cannot use drugs or purchase them inside the facility. With a need to regularly use, and to also therefore regularly buy illegal drugs, a situation is set up that effectively requires constant flow in and out of to purchase and use. Each user typically requires a fix 2-3 times a day. Because drug laws are much harder on large amounts, dealers now only sell in small amounts, which increases the frequency of sales. With the vast majority of the chronic homeless being users, each 100 bed facility will drive up to several hundred trips per day into the surrounding neighborhood to either shoot up or buy drugs.

Commentary. It should not need to be said, but apparently, it does: having several hundred instances per day of people shooting up or buying drugs concentrated into a small area is a bad thing for that neighborhood. Just as a couple of things to note, people who have just shot up are at their most vulnerable and most dissociated from reality; having a large number of users regularly buying in a small area makes that turf very valuable to drug dealers, which often leads to violence. 

• Not enough beds to enforce “No Camping” ordinance. The last homeless census said that there were ~5,600 homeless in Sacramento, by 2021 this number will exceed 6,000 people in the Sacramento region who are experiencing homelessness. 

Commentary. With only 800 beds, the City Plan will procure less than 15% of the beds needed to enforce the law, and this is if the City achieves all of its goals.  This in turn means that the City Homeless Plan is effectively writing off enforcement of this law. Not only does this mean continued pain for both permanent residents (excrement, indecent exposure, hypodermic needles, etc.), it also means continued pain for those living on the street. Since 800<5,500, the City Plan is quite literally a Plan to fail. 

• Inefficient use of resources. The expenditure plan uses hundreds of millions of dollars of one time funds but will only produce temporary facilities that are doomed to fail those that need help most. 

Commentary. Instead of investing in permanent facilities the City is proposing to use the funds it has received on temporary facilities. The expenditure of one time occurring funds as proposed is not only bad policy on its own, but is also a tragically lost opportunity to achieve a constructive and effective long-term solution. 

• Inefficient use of all resources. The expenditure plan seeks to provide duplicated services at each of the individual facilities. 

Commentary. From an efficiency standpoint it is well known that multiple small locations are a less efficient use of resources than centralization. This in turn impacts operating costs, which is particularly important for a system of shelters built with one-time funding and without a long-term source of operating funds identified. Effectively, it means that the policy choices made now will increase operating costs in the future, thereby adding additional expenditure drag to future budgets.

Commentary. The City Plan will evict dozens of housed, stable, and low-income seniors (and some disabled) in order to create a temporary low barrier facility. This will create a new set of homeless individuals while only creating a temporary facility of roughly equivalent size.

One counter point by the City is that the current residents can stay there if they like. If this ends up being the case, then why spend $10M? Another idea floated by the City is that perhaps the Sacramento Housing and Redevelopment Authority (SHRA) would be able to find housing for the current Capitol Park Hotel residents. However, SHRA currently has an extensive waitlist for housing, so when would that occur? If the CPH residents are to be moved to the front of the line over the people currently on the wait list, then they will be taking housing that would have gone to others, effectively keeping others homeless longer than they otherwise would have been. The math and logic is simple: the City of Sacramento cannot address the homeless issue by taking housing away from those who already have it.

• Cutting in line. The City has moved to place homeless individuals at the front of the line for subsidized housing, displacing those who have been waiting for available units to come open for years.

Commentary. The amount of subsidized housing available in Sacramento is limited and in great demand. Previously, priority was given to families, particularly those with young children, but the combination of restricted supply and low turn-over meant that, even after qualifying, families could wait years for an opportunity to open. The City has now committed to move roughly 500 homeless individuals to the “head of the line”. This effectively lets them “cut” in front of hundreds of families who had previously waited their turn.

Foundational beliefs

The City of Sacramento’s plan is built around several foundational beliefs. These beliefs are the guiding principles that undergird the City’s plan.

1.  “We must meet people where they are”. This idea holds that to be effective, chronic homeless must be provided services in the location where they are currently residing. However, there is nothing other than local policy decisions that mandate this approach. When this leads to homeless shelters in inappropriate locations, and constraints on facility size, it should be apparent that the premise is wrong, but the City continues with the current plan.

2.  The chronic homeless have a right to be where they are. The question is not whether anyone has a right to be in a given city. Anyone has the right to walk down the streets of Beverly Hills, and no one can stop them, but that right to be present does not give the right to break any laws. The question instead is do the chronic homeless have a right to defecate in the street, drop syringes, destroy landscaping through trespassing, vandalize fences, undermine levees, or engage in any other anti-social activity prohibited by law. The question answers itself: no one has a right to break laws.

3.  The chronic homeless are all from the area where they are sleeping. This seems improbable for multiple reasons. First, some portion of the chronic homeless population show up with one way bus tickets from other places. Second, it does not seem like too many people have grown up downtown over the last 40-50 years because there is almost no family oriented housing there, but that area of our city is a hotbed for the chronic homeless. Lastly, while the final census numbers are not back yet, the number of homeless in Sacramento seems to be growing dramatically. It seems reasonable that not all of this increase is solely from organic growth in our community.

This viewpoint also ignores the dumping of primarily mentally ill patients in California through a program sometimes known as “Greyhound Therapy”. The Sacramento Bee was nominated for a Pulitzer Prize[1] for a series of articles[2] on the issue. The Bee found that one mental health facility alone had 

bused roughly 1,500 patients out of Nevada between 2008 and 2013, a third of them to California. Some of the patients, The Bee documented, became homeless and went missing after their bus trips. Some died tragically. Some committed serious crimes in their new cities.[3]

While the people who were the victims of this Greyhound Therapy are certainly not to be punished for what happened to them, the fact of this well known practice does undercut the City’s contention that all the chronic homeless we see are from that area.

4.  It is better to do something than nothing. Just because someone is working on a plan doesn't mean that it is commendable, especially if the plan is known to be doomed to failure from the start. Sacramento has thousands of homeless people yet the City's plan, even if nothing goes wrong, will only provide 800 beds. Since the courts have said (Martin v. Boise) that camping ordinances cannot be enforced unless there is sufficient bed space, and since 800 is less than 3,000, then even IF the city were to achieve its goal, it would still not be able to enforce the no camping ordinance. 

Further, this is more than just bad policy, it is also going to be a tragic lost opportunity if it goes through. There are tens of millions of dollars in one time funds that are planning to be spent, dollars that could have gone to a permanent solution. 

5.  We cannot get the chronic homeless to move. This is false: there is nothing but a policy of refusing to enforce existing laws that stops peace officers from getting the chronic homeless to move. Moreover, in addition to failing to help the suffering of the chronic homeless population in particular, failing to enforce the law in such an obvious way is also extremely detrimental to the rule of law in society at large. When society sees overt, public, habitual, and unrepentant violation of numerous laws, the observance of all laws is made impossible. 

6.  We cannot find a location. The City of Sacramento has the power of eminent domain. If property owners with locations with unique characteristics needed for a successful program refuse to sell voluntarily, the City can condemn the location and acquire it through eminent domain, paying fair market value for the property.

7.  The chronic homeless are not a threat to themselves or others. Most people with mental illness, even untreated mental illness, are not a threat to themselves or others, but a disproportionately high portion are. This is particularly true when untreated mental illness is combined with substance abuse. The following example comes from a large study

an unselected birth cohort of 11,017 individuals was followed for 26 years. Men with schizophrenia without alcoholism were 3.6 times more likely to commit a violent crime than men without a psychiatric diagnosis. Men with both schizophrenia and alcoholism were 25.2 times more likely to commit a violent crime[4].

It is worth noting that the City of Sacramento estimated that over 50% of the residents at the Railroad Avenue facility had debilitating mental illness (primarily schizophrenia, bipolar, and depressive disorders), and the CHP estimates that over 90% of the chronic homeless population are addicted to either heroin or methamphetamines.

Additional information on this topic is included at the end of this document.

8.  This is a national issue. Not all cities have the degree of problems that Sacramento, San Francisco, and Seattle have. San Antonio, which has taken a completely different policy path than Sacramento has reduced street homelessness by almost 90%. Vacaville, which has opened significant shelter space and services, as well as started enforcing existing laws, has also dramatically reduced homeless related issues such as hypodermic needles, human waste on streets, indecent exposure, etc. Stating that the Sacramento version of chronic homelessness is a nationwide issue disconnected from local policy decisions is both factually incorrect and misleading.

Haven for Hope Model in San Antonio 

There is a better way to address the homeless issue, one that is much more effective. The San Antonio “Haven for Hope”[5] model has not only shown great success, it is being replicated across the country. The San Antonio model combines both a “wet” facility for basic shelter/triage with an intensive wrap around care for those who choose to move towards recovery[6]

• Central intake
  • Basic services
    • Beds
    • Sanitary facilities
    • Food
    • Lockers for personal belongings
    • Kennel space for pets
  • Support
    • Basic medical care
    • Detoxification services
    • Basic Mental/behavioral health
  • Austere
  • Low Barrier
  • Located in an Industrial area
  • Has sufficient bed space to allow enforcement of the no camping policies
• Follow-on services
  • Improved housing
  • Provides a path to recovery
    • Substance abuse treatment
    • Mental behavioral health
    • Job training
  • Multiple organizations working together in one location
  • Only for those making a commitment to recovery
  • Immediately adjacent to “Low Barrier” facility, allows people who have not made a commitment to recovery to see the better lives of those who have on a daily basis

Impacts of Haven for Hope[7]

·  Street homelessness reduced by 80% in San Antonio

·  For those that complete the second phase

o  90% of those who complete second phase still in housing 1 year later

o  71% have retained employment 6 months or more

·  Jail Recidivism rate

o  County Average 80%

o  Those who went to Low Barrier facility 32%

o  Those who went to campus 24%

·  Tens of millions of dollars saved per year in jails, Emergency rooms, street cleaning, etc.

Hope for Sacramento Model

• Mandate that the City open a Central intake/Triage facility
  • Low Barrier
  • Zoned appropriately- same zoning as was originally proposed for cannabis
    • Industrial/heavy commercial
    • Minimum distances from schools/playgrounds/child care/etc.
  • Sufficient bed space to allow enforcement of no camping laws (which are already existing)
  • Appropriate supportive facilities
    • Security 
    • Bathrooms
    • Showers
    • Temporary storage for goods
    • Kennel/cat house
    • Basic meals
    • Detox/inebriation treatment
    • First aid/medical triage
• Encourage colocation of wrap around services by private charities as in San Antonio in Follow-on/transitional facilities
  • Encouraged
  • For those who have completed transformational campus but awaiting permanent housing
  • Can use scattered site model
  • Require Drug testing
  • Require Sex offender Screening
• Develop a “third leg” collocated jail diversion facility
  • Petty crime
  • Minor drug offenses
  • “Better than jail” alternative
• Eliminate barriers for faith based orgs to help
• Extend rules for City Hall to rest of City
• Suspend requirement for City to open its own facility if City and County agree on joint facility
• Sunset Mechanism on failure

If the City will not move from the current plan towards a San Antonio model, the Hope for Sacramento group will form a committee to promote a citizen’s ballot initiative to mandate such an approach.

Addendum 1: Violence risk

The City of Sacramento continues to hold a position that the homeless population is not a threat to the physical safety of people living here. Some, such as Councilman Harris, even go so far as to argue that the lack of a tragedy to date shows that there is no threat. This position denying that the homeless population poses a threat of physical violence is at odds with most non-politically motivated, independent academic research published by the National Institutes of Health, as well as common sense.

The reason for this is simple: in Sacramento the homeless problem is not one of people with Mental Health or Substance Abuse issues, it is largely one of a group of people who have BOTH Mental Health and Substance abuse issues. The City has reported that 54% of those at the Railroad Avenue facility had mental health issues, but this is likely an under-reporting of the issue due to selection bias of the population at that location. Information from the CHP reports that ~90% of the chronic homeless in Sacramento have substance abuse issues, primarily meth and heroin. As the literature clearly shows, the combination of Mental Health and Substance Abuse issues substantially raises the risk of violence.

Below is a small selection of the numerous scholarly articles on this subject. Keep in mind that substance abuse in these studies is often only referring to alcohol, and that the effects of meth and heroin are likely to be higher.

NIH Study #1

METHOD: A detailed Medline analysis was performed and relevant studies were reviewed.

RESULTS: A large number of studies have linked substance misuse in schizophrenia with male gender, high incidence of homelessness, more pronounced psychotic symptoms, non-adherence with medication, poor prognosis, violence and aggression. The latter has been proved by clinical, epidemiological and longitudinal prospective studies of unselected birth cohorts. The increased risk for aggression and violent acts cannot be interpreted only as a result of poor social integration. Male gender, more severe psychopathology, a primary antisocial personality, repeated intoxications and non-adherence with treatment are important confounding variables.

CONCLUSION:  Substance misuse has been shown consistently to be a significant risk factor for violence and disturbed behaviour.

https://www.ncbi.nlm.nih.gov/pubmed/10827882/

NIH Study #2: Substance Abuse increases risk of violence in the Mentally Ill

In comparison to the general population, the risk of homicide is increased 8-fold in schizophrenics with a substance abuse disorder (mainly alcohol abuse) and 2-fold in schizophrenics without any comorbidities.

https://www.ncbi.nlm.nih.gov/pubmed/23816066

Unselected Cohort test shows that Mental Illness + Substance Abuse increases risk

an unselected birth cohort of 11,017 individuals was followed for 26 years. Men with schizophrenia without alcoholism were 3.6 times more likely to commit a violent crime than men without a psychiatric diagnosis. Men with both schizophrenia and alcoholism were 25.2 times more likely to commit a violent crime. 

https://www.treatmentadvocacycenter.org/storage/documents/backgrounders/smi-and-risks-for-violence.pdf

NIH Schizophrenia + substance abuse research #1

RESULTS: In patients with schizophrenia, 1054 (13.2%) had at least 1 violent offense compared with 4276 (5.3%) of general population controls (adjusted odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.2). The risk was mostly confined to patients with substance abuse comorbidity (of whom 27.6% committed an offense)

https://www.ncbi.nlm.nih.gov/pubmed/19454640

NIH Schizophrenia + substance abuse research #2

Risk estimates of violence in individuals with substance abuse (but without psychosis) were similar to those in individuals with psychosis with substance abuse comorbidity, and higher than all studies with psychosis irrespective of comorbidity. 

CONCLUSIONS: Schizophrenia and other psychoses are associated with violence and violent offending, particularly homicide. However, most of the excess risk appears to be mediated by substance abuse comorbidity.

https://www.ncbi.nlm.nih.gov/pubmed/19668362

NIH study: Not just Schizophrenia either

RESULTS: There were statistically significant increases of risk of violence in schizophrenia and in bipolar disorder in comparison with general population. The evidence suggests that the risk of violence is greater in bipolar disorder than in schizophrenia. 

CONCLUSIONS: Violent behavior of patients with schizophrenia and bipolar disorder is a public health problem.

https://www.ncbi.nlm.nih.gov/pubmed/23470603

METHOD: The aim of this study was to investigate the factors associated with violent behavior in a large multicenter sample of Homeless Schizophrenia (SZ) and Bipolar Disorder (BD) (HSB) subjects.

RESULTS: During the 6 months before evaluation, 213 (34.3%) committed at least one physical or verbal violence.

https://www.ncbi.nlm.nih.gov/pubmed/30423419

Addendum 2: Superiority of Housing First/Scattered shelters

The City of Sacramento continues to hold a position that the Housing First and Scattered shelter models are the most effective way to help those facing homelessness. Further, they hold that the added risks and impacts that these approaches impose on the rest of the community are justified by the superiority in outcomes associated with Housing First/Scattered Shelter. However, peer reviewed research does not support this contention. 

It is important to note that this reporting of ineffective impacts is despite a very strong cultural bias towards finding reasons to support the Housing First/Scattered Shelter approach in some parts of the academic community. The general way that this would appear would be in the format of “homeless people are still in housing 2 years later if we pay for it, but there has been no change in the rate of substance abuse”. Far from being proof of success, these studies are instead proof of program failure. In a successful program (as is the case with Haven for Hope), those in need would transition out of a program and reintegrate into society. A program that “warehouses” people without delivering any change in substance use only means that those who have been “helped” are in limbo: no longer on the street, but dependent on program continuation to stay in a “limbo” status between the street and reintegration.

NIH cited study: pragmatic randomized trials investigating Housing First for homeless and mentally ill adults.

Method: Those with High Need were randomized to Housing First with Assertive Community Treatment (HF-ACT), congregate housing with support, or usual care

RESULTS:  Minimal significant differences were found between study arms following randomization. 438 participants (88%) provided consent to access administrative data.

CONCLUSIONS: Randomization resulted in no meaningful detectable differences between study arms.

https://www.ncbi.nlm.nih.gov/pubmed/24176253

Method: Two concurrent randomized controlled trials with 24-month follow-up compared outcomes of Housing First or Treatment as usual care

CONCLUSIONS: Housing First, an intervention to support recovery for homeless people who have co-occurring mental illness and substance use disorders, did not reduce daily substance use compared with treatment as usual after 12 or 24 months.

https://www.ncbi.nlm.nih.gov/pubmed/26052657

https://www.ncbi.nlm.nih.gov/pubmed/30777888

METHOD: This study used longitudinal data from a randomized controlled trial of housing first (HF) to examine predictors of recovery among homeless people with mental illness.

ABSTRACT: Receipt of Housing First did not have any effect on changes in recovery scores at follow-up.

https://www.ncbi.nlm.nih.gov/pubmed/30519803

NIH cited study shows that 68% of Housing First research does not even look at self-harm

BACKGROUND: Despite housing active substance users, harm reduction is an often-overlooked element during the Housing First implementation process in real-world settings. In this paper, we explore the representation of the Housing First model within the open-access scholarly literature as a potential contributing factor for this oversight.

METHODS: We conducted a rapid review of the US and Canadian open-access Housing First literature. 

RESULTS: A total of 55 articles on Housing First were included in the final analysis. Only 21 of these articles (38.1%) included explicit mention of harm reduction

CONCLUSIONS: Our review demonstrated a lack of both explicit mention and informed discussion of harm reduction in the Housing First literature, which is likely contributing to the Housing First research-practice gap to some degree. 

COMMENT: What this study from 2017 states is that in most “research” on the subject (68%), the “researchers” did not even ask any questions about self-harm, including continuing substance abuse. Of those studies that did publish results on this question, few (IF ANY) are showing reductions in substance abuse. This makes it clear that much of the published research on Housing First is either incomplete or intentionally deceptive on its effectiveness at addressing the root issue needed to transition to a normal life, and most of the research that has been published that does address the issue shows Housing First to have no impact. It is therefore difficult to see why the City continues to claim that research supports the superiority of housing first.

https://www.ncbi.nlm.nih.gov/pubmed/28535804

[1] https://www.sacbee.com/news/investigations/nevada-patient-busing/article2595722.html

[2] https://www.sacbee.com/news/investigations/nevada-patient-busing/

[3] https://www.sacbee.com/news/local/homeless/article205931264.html

[4] https://www.treatmentadvocacycenter.org/storage/documents/backgrounders/smi-and-risks-for-violence.pdf

[5] https://www.youtube.com/watch?time_continue=242&v=9BKfgqVnHno

[6] https://www.havenforhope.org/OurApproach

[7] https://capitol.texas.gov/tlodocs/84R/handouts/C3822016081610001/abb0ed96-6a1d-44bb-a5b1-078a38f1a28c.PDF