What about mental illness and addiction?

Advocates for homeless people are leery of casting too much blame for the state’s crisis on mental health and substance abuse issues. They argue that plenty of low-income residents in other states struggle with drug addiction and debilitating psychological conditions. They simply manage to remain off the streets because the rent is cheaper.

But recent data suggests these issues are more prevalent among people experiencing homelessness than previously reported, especially for those living on the street. A Los Angeles Times investigation found two-thirds of L.A. County’s residents living on the streets suffer from a psychological or substance abuse disorder or both, far more than what’s been reported in official statistics. 

Officially diagnosed illnesses are much lower, however. Janey Rountree, founding executive director of the California Policy Lab at UCLA, said a recent study found that 20% of 37,000 people experiencing homelessness in Los Angeles had a clinically diagnosed serious mental illness within the last 12 years, whereas about a quarter of Los Angeles’ homeless population suffers from any mental illness. 

Of the more than 248,000 people who accessed homeless services throughout 2020, 41% reported disabling conditions, which could be anything from diabetes or a broken leg to a mental health disorder, according to Ali Sutton, the state’s deputy secretary for homelessness at the California Homeless Coordinating and Financing Council.

Methamphetamine use is up across the West Coast, and is often to blame for some of the most visible episodes of homelessness seen on California streets. Unfortunately, physicians say meth addiction is confoundingly difficult to treat. While methadone is available to wean heroin addicts off of opioids, no such replacement medication exists for meth.

Worse still, meth can exacerbate existing mental illnesses. Addiction and psychological conditions are often inextricably intertwined, and present a complex case for outreach workers or (more often) law enforcement to confront. A disconcerting number of California board-and-care facilities, which have traditionally housed low-income patients with schizophrenia and other severe conditions, have shuttered in recent years.

Many have also blamed California’s conservatorship laws for making it too difficult to compel treatment for people with mental illness or drug addiction living on the street. Civil libertarians and disability rights groups argue that conservatorship —when a court-appointed official manages another person’s life, including medical decisions — should be used as sparingly as possible, as it risks violating civil liberties and is a hollow remedy given the severe shortage of actual treatment options. Under a 1967 state law known as the Lanterman-Petris-Short Act, Californians can be held for treatment against their will only if they are deemed a danger to themselves or others, or are determined to be gravely disabled. Other states such as New York do not impose such strict requirements. Candidates in California’s recall election pushed to loosen these restrictions, but were ultimately unsuccessful.

Finally there is the eternal question of cause and effect: The severe stresses people face when they lose shelter and are forced to live exposed on the streets can also wreak havoc on their mental health and lead to substance abuse.

Margot Kushel, a professor of medicine who leads the UCSF Benioff Homelessness and Housing Initiative, says there’s little evidence of correlation between mental health and homelessness. But once people are living on the street, they’re much more likely to turn to drugs or alcohol.