Trump's executive order on homelessness

I had been thinking about writing about homelessness, or at least adding to the comments in my "Quote of the day: homelessness" entry from 2022, because of the Seattle Times article, "Homeless people visited ER less after moving into King County’s hotels."

The concept of "housing first" is based on the idea that putting people in a more stable housing situation, regardless of whether or not they continue to partake in drugs and alcohol or exhibit mental illness, they are easier to help, and it saves the government money, even if it doesn't fit with moral, "you should stop," concepts about who "deserves" help and who doesn't.

Then Trump came out with an executive order ("Ending crime and disorder on America’s streets") changing federal policy on homelessness, towards the "moral" side, not the practical evidence-based policy side.  Among other elements it bans encampments on public space, something he has no control over unless it is federal property.

From the Los Angeles Daily News article "Trump’s crackdown on homelessness: What does it mean for California?," 

Trump doesn’t want to stop at banning homeless encampments and pushing people into treatment, and that’s where he and Newsom diverge: The president wants to upend two core tenets of California’s homelessness policy. 

Trump wants to abolish federal support for “housing first,” which is the idea that homeless individuals should get housing even if they are still using drugs, and “harm reduction,” which focuses on preventing overdoses and otherwise making drug use safer. Both tenets are backed by research and have been the gold standard in California — and at the federal level — for years.

Groups are concerned that their systems of program delivery for homeless services will no longer qualify for federal funds.  From the LADN:

Trump’s order also prioritizes committing more people to institutions from the street. The order seeks to make it easier to commit people with mental illness who can’t care for themselves, while also promising grants and other assistance to help ramp up commitments, and threatening to divert funding away from places that don’t push people into treatment facilities “to the maximum extent permitted by law.” It also promises to prioritize funding to expand mental health courts and drug courts. 

The likelihood of federal monies being provided to local and state governments to deal with mental illness in this way is remote given the cutbacks in other programs like Medicaid.

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I can't remember what article I read, but it made the point that the overall counts of homeless people done by local governments include people who are housed in domiciles in which they are guests.  While I knew that, it accounts for research finding that a majority of the homeless don't have substance abuse or mental health issues ("Here's what largest study in decades of California homelessness found," San Francisco Chronicle)..

The fact is that the etiology of street homelessness is different than homeless in temporary housing.

More seniors are homeless.  The major point of the LA Times column "Trump’s order on homelessness gets it all wrong, and here’s why," is that despite reports showing a stabilization of numbers in the homeless population, the mix is changing and that more seniors are finding themselves unhoused because of income and high housing costs, not from behavioral issues.

Who identifies problems and addresses them at the metropolitan scale? No one, at least when it comes to mental health-related police shootings

The DC metropolitan area is made up of DC, and parts of Maryland, Virginia, and West Virginia, according to the definition by the US Census.  If you count the DC-Baltimore region as defined by the Census, it also includes a bit of Pennsylvania.

In any case, each area, DC and Baltimore, has its respective organization of governments, in DC, it is the Metropolitan Washington Council of Governments and in Baltimore, the Baltimore Metropolitan Council.

I don't pay as close attention as I should to these organizations, but it's not like they have units comparable to the Municipal Research and Services Center in Washington State or the Independent Budget Office in New York City, not to mention various advocacy groups or think tanks or university research centers, that monitor various issues and produce reports.

In some areas, the leading newspaper has a role as a kind of system integrator.  Newspapers that come to mind that have written important series that lead to major changes in their communities include the Orange County Register, San Diego Union-Tribune, and the Boston Globe.

I wrote a few months ago ("Police response to mental health matters") about a set of police shootings in the Washington area, where people who were mentally ill ended up being killed.  I mentioned how the Orange County Register had written a series of investigative articles about the County's mental health system and the gaps that contributed to similar killings there, and how, while it took awhile, the County is setting up special mental health units at key hospitals.

Fairfax County Police released surveillance video, edited for length before its release to the public, showing the fatal shooting of Jovany Amaya Gomez by sheriff’s deputy Patrick McPartlin on Aug. 15, 2016, outside of Inova Fairfax Hospital. Gomez was mentally ill. (Fairfax County Police) Via the Washington Post.

I bring this up again because the Washington Post reported ("Fairfax prosecutor says shooting of mentally ill man outside hospital was justified") that the police officer involved in the incident in August that led me to write the blog post was exonerated. Interestingly, in something that I don't think was reported earlier, it seems like the hospital "dropped the ball" equally. From the article:

While the report means no criminal charges will be filed in the case, it reveals some challenges in how Fairfax County law enforcement officials deal with the mentally ill, particularly those among the county’s growing immigrant population who don’t speak English.

On the sweltering day of the shooting, Amaya, a Honduran national, initially approached a county police officer sitting inside his cruiser off Little River Turnpike in Annandale, according to the report.

Unable to understand the Spanish-speaking immigrant, the officer used his cell phone to call up Google’s language translation application, which helped him determine that Amaya wanted to hurt himself.

The officer had Amaya transported to the hospital with the intention of taking him to the county’s Merrifield Center for mental health treatment if tests showed signs of mental illness.

But a Spanish-speaking nurse said Amaya complained only of a stomach ache and did not appear to want to hurt himself. Amaya was discharged with a doctor’s instructions to return for a follow-up examination.

More recently, the Boston Globe has done a similar series of articles ("Spotlight: The desperate and the dead") about the gaps in mental health related care in Massachusetts, and the last piece in the series, "San Antonio became a national leader in mental health care by working together as a community," focuses on the system that has been created in San Antonio/Bexar County, Texas to address the problem.

What stuck out to me is how the San Antonio Police Department has created a special mental health response unit and they've created an "Involuntary Outpatient Treatment Program," to address providing help to people who need but refuse it. From the article:

... But this peaceful, mediated outcome is why the mental health unit exists. They want people in crisis to submit to help, and to see police as partners in making that happen.

The seven-person police unit is just one piece of a larger behavioral health care system in San Antonio and surrounding Bexar County that’s widely considered to be a national model. Over the past decade and a half, San Antonio community leaders, government officials, law enforcement, judges, medical institutions, and the county mental health authority have made tremendous strides together in identifying and treating people with mental illness.

Even though the Washington Post reports on police shootings of people in mental health distress across the metropolitan area on a regular basis, it's clear that a systemic, structural, and improved approach is nowhere on the horizon.

Note that the UK has a community nursing program that functions on an outpatient basis similarly to the San Antonio Police Department's Mental Health Unit, but in the face of the UK national government's systematic cuts to local budgets and to the National Health Service, that system is breaking down ("For the first time in my nursing career, I ​think: I can't do this any more," and "Social care: why are we 'beyond the crisis point'," Guardian).

Police response to mental health matters

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Revised and re-dated due to addition of additional examples in Fullerton, CA and Manchester, NH.
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The death of people in mental distress at the hands of first responders, usually police, is an issue that's been in the news for as long as I can remember.

Since "mental hospitals" started closing in the 1960s (e.g., "State mental hospitals were closed to give people with mental illness greater freedom," Boston Globe), despite the creation of the community mental health system, mostly it has been underfunded and people with mental health problems are mostly abandoned to the streets, where police are the primary maintainers of order.

When the primary tool of a first responder--a police officer--is a gun, it shouldn't be a surprise that lots of people having mental health episodes get killed by police officers ("POLICE CONFRONTATIONS: Families failed by a broken mental health care system often have no one to call but police," Boston Globe). From the article:

Nearly half of people killed by Massachusetts police over the last 11 years were suicidal, mentally ill, or showed clear signs of crisis, a Spotlight Team investigation shows. The deaths are the heavy human toll of an ongoing collision between sick people failed by the mental health care system and police who are often poorly equipped to help, but are thrust into this dangerous role.

Each death is unique, yet certain scenes replay: The suicidal man who steps toward police with a knife. The distraught young adult pointing a pellet gun that looks real. The troubled son, off his medication, swinging a machete, a screwdriver, a stick. Such provocations are motivated not by violent intent, typically, but rather by self-destructive despair or delusions. At least seven of those killed statewide from 2005 to 2015 yelled “Shoot me!” at officers, according to police reports. So did Robert L. Dussourd, 44, killed earlier this year by police in Braintree — one of at least four apparent suicide-by-cop attempts reported in and around Boston so far this year. ...

Recent efforts by journalists to count them, notably at The Guardian and The Washington Post, found that mental health was a likely factor in at least one-quarter of all fatal police shootings in the U.S. last year.

This happened last week in Fairfax County, Virginia. The person killed, Giovanny Martinez, had been admitted to a hospital but then released. Afterwards, he charged a police officer, who shot and killed him ("He sought an officer because he was suicidal, but was killed by a deputy. A family wonders: Why?," Washington Post).

St. Joseph Hospital of Orange's secured Emergency Clinical Decision Unit has 12 beds and serves as a holding area before placing psychiatric patients who are brought in to the emergency room.  Mindy Schauer, OC Register.

Creating mental distress units at local hospitals: Orange County, California.  Simultaneous with the local reports from Fairfax County (which has in the past few years experienced killings by police of at least two other people with mental health issues), last week, the Orange County Register reported ("County to get first emergency centers for psych patients, unburdening hospitals") on how special mental health units will be created at two hospitals in the county, to better address the needs of people in mental distress.

Apparently, this type of health service is widely provided in California. From the article:

Orange County is set to get its first emergency medical centers dedicated to treating people who suffer sudden psychiatric episodes, addressing a void that critics say long has burdened local hospitals and left mentally ill patients with inadequate treatment. ...

Hospital emergency rooms generally are ill-equipped and often lack the proper expertise to treat patients suffering psychiatric episodes, said Dr. Michael Brant-Zawadski, executive medical director of Hoag Neurosciences Institute. Likewise, those same patients often don’t need to be held at inpatient psychiatric facilities, which keep people for multiple days.

The county’s new “crisis stabilization program” will provide a middle-ground treatment method that currently is missing.

“Patients could be evaluated, discharged and transferred to the proper outpatient treatment program,” Brant-Zawadski said. “Other counties, like Alameda, already have a robust psych emergency program, where ambulance and cops take people who have mental issues to those places instead of emergency rooms.

“This is a great step forward,” he said.

Once the centers open, all Orange County police and emergency medical personnel will be told to take people suffering mental episodes or those under involuntary psychiatric holds to the new centers. Patients will be able to stay at the new facilities for just shy of 24 hours, at which point they’ll need to be released or transferred to an inpatient facility.

The response in Orange County was in part due to the OCR investigative series published on the problem in 2014 (e.g., ""A severe shortage of psychiatric hospital beds has turned Orange County emergency rooms into virtual boardinghouses for psych patients" and "The push to create Orange County's first dedicated psychiatric emergency centers") helped spur the County to action.

Street teams of police officers and crisis workers in Boston's Mattapan neighborhood. Separately, the Boston Globe reports ("Officers act as ‘guardians’ on the city’s streets") on a program where two police officers and a mental health crisis worker comprise a team that two days/week goes out into the field and aims to help people living on the street in proactive ways, rather than giving them tickets, arresting them, etc. From the article:

When Officers Michael Sullivan and Jeff Driscoll and senior crisis clinician Ben Linsky head out on their beat in Mattapan, they seek out the most vulnerable citizens: the drug-addicted, the homeless, and the mentally ill. Theirs is the only unit of its kind in the city, and its mission since it was started in February is to help, not arrest, people like Edward. 

...  Sullivan, Driscoll, and Linsky, who make up Mattapan’s “Operation Helping Hands,” spend two nights a week freed from dispatch calls. Instead, they get to know the people on the streets, figure out what services they need, and try to provide them.

“You’re one part social worker, one part cop, and one part older brother,” Sullivan said. ...
Linsky, 34, who works for the Criminal Justice Diversion Program through Boston Medical Center and the Boston Police Department, thought he would work with police only until he could get into medical school — but five years later, he hopes to become a police officer. When he’s not riding with Driscoll and Sullivan, he’s responding to 911 calls that involve people with mental health issues.

Apparently, Framingham was the first city in the state to develop such a program, and since then many other cities across Massachusetts have launched similar initiatives.

Fullerton California completely revamps use of force, training, and other practices after the after a police officer beat to death a homeless man.  After the fatal beating of Kelly Thomas, a schizophrenic (the city paid a big judgement to his family) rather than accept what happened as "an accident," the City of Fullerton evaluated various police processes and changed them, to reduce the likelihood of injury and death in interactions between the police and the public ("Here's how Fullerton police have improved since Kelly Thomas' death," Orange County Register).

The changes in practice were not limited to dealing with homeless people or people in mental distress, but in how all of the city's police officers interact with the public and how they are trained.

The police department has set a goal of being one of the best police departments in the country for its size, and measures its success in part   The OCR article reports on the most recent review:

The study offers a half-dozen recommendations – compared with 59 in its first review – that range from striving to use the least force necessary to more cautious foot pursuits. 

.. Four years ago, OIR Group recommended that officers – when safely possible – employ less force by increasing time and distance, using cover and concealment, creating barriers, and calling and waiting for backup. 

“The department,” the document says, “has substantially addressed many of the shortcomings we noted in our 2012 report.”

First, a new training room was built for officers to practice lesser-force techniques. Then, a video-based interactive training system was installed. It offers more than 200 bad-guy scenarios, and each one can be altered with the touch of a screen.

“These upgrades in training facilities,” the report concludes, “allow trainers to emphasize the importance of tactical alternatives to force, particularly deadly force.”

The training may be paying off. Citizen complaints have dropped from a high of 36 in 2014 to a low of 24 last year.

Still, the new report offers new suggestions. They include requiring incident reports to check off threat perception, least-use-of-force efforts, and adherence to reporting policies.

The process in Fullerton is appears to be a national model, unlike the whitewashes that seem to be happening in most other cities when it comes to evaluating police departments and officers in terms of excessive force and deaths at the hands of police officers.

-- Fullerton Police Department: Audit of Force Reviews and Internal Investigations, August 2016, OIR Group

Fire Department EMS officer Christopher Hickey, right, talks with a walk-in addict at the main fire station in Manchester, N.H., on Aug. 10. PHOTO: CHERYL SENTER FOR THE WALL STREET JOURNAL

Manchester, NH: fire stations as point of contact for help for drug addicts.  This isn't a first response to mental distress matter exactly, but, the Wall Street Journal reports, "Fire Stations Open Their Doors to Addicts" how Manchester, to deal with its rampant substance abuse problems--the city has about 8 deaths per month from drug overdoses--they have created an empathetic/non-judgemental response system where people seeking help can go to the local fire station without fear of being arrested, and then get help and referrals to nonprofit drug rehabilitation and other programs.  The city has provided funds to the nonprofits so they can provide the necessary programming.

Conclusion.  Clearly, programs like these are overdue for Fairfax County and many other communities.  It's not like there aren't proven better models for practice.

-- "After a year with no answers in Fairfax police slaying of John Geer ...," Washington Post
-- "James Bryant killed by police outside Fairfax County homeless shelter," WJLA-TV
-- "Fairfax jail inmate in Taser death was shackled," Washington Post