Spike's Place

What is the loving thing?

I wrote last week about our mission on earth to love each other. No question perplexes me more as to what "the loving response" is than homelessness. A commentary published at the San Francisco Chronicle highlights the complexities.

In it, C.W. Nevius writes of a homeless man, James Allen Hill, who died in a public library restroom of an apparent overdose. Of course it's a tragedy, another life snuffed out by drugs and despair. Nevius says the very homeless advocates trying to "help" Hill allowed his death.

There will be those who will see Hill's death as a failure of the system, another example of how the city neglects its poorest residents.

That's not the story here. The city did anything but neglect Hill. But his case does show a flaw, all right: Chronic and incorrigible offenders avoid the consequences of their actions - aggressive panhandling, public urinating or drunkenness - often through the help of well-intentioned attorneys for homeless advocates.

And instead of being placed in treatment, the offender goes back on the street and continues his destructive behavior.

San Francisco is the same city that gave its homeless population monthly stipends. One of the things you often hear from advocates for the homeless is "the right to be homeless", i.e. that it's unfair for charitable programs dedicated to serving the homeless to have putting that person "back into society" as one of their goals. What if they don't want to be a part of society?

I have to admit this is a question I've struggled with from the time I first started learning about homelessness and in the brief time I did homeless outreach. I still don't feel like I know what the answer is. Perhaps there are hundreds of different answers. There's no question that the pro bono attorneys who kept Mr. Hill out of prison or treatment programs thought they were doing the right thing and were taking care of him by giving him a voice against the legal system, but what if he would have been better served by being put in an addiction treatment program, a housing program, and put on the track to a stable life with a home and a job? And at what point do we deem someone irredeemable?

One day, when I have the courage, I am going to find out the answer to this question:

What do homeless people want?

Of course there are going to be people who want to have a stable life and a stable housing situation. But what of the people who don't want that? How best help them? And is it condescending to even be asking these questions? Do they want to be helped? Do they want to be left alone? I feel like we as a society still don't understand the answers to these questions and it's leading to paternalistic approaches that may be counterproductive. As previous posts indicate, I feel that we are on this Earth to serve each other, but what about when what's "helpful" is so unclear? I'm still at a loss.

For myself, I don't give cash to panhandlers, and I donate to organizations with a charitable mission. That's going to have to do for now.

Minnesota trying to end Chronic Homelessness

A couple weeks ago, I was talking about Malcolm Gladwell's article discussing a way to end longterm homelessness. It turns out that Minnesota's governor, Tim Pawlenty, has already been trying a similar plan for several years. His goal is to end chronic homelessness in Minnesota by 2010. Minnesota Public Radio published an article last week with an update on how the plan is going. So far, they've been able to fund over 650 new housing units, though most of those have yet to be built. The whole plan is going to cost $540 million, but $180 million of that has to come from federal housing money. As we all know, Bush's budgets don't have a lot in them for social programs that might actually do some good, so it looks like this program may be somewhat underfunded. However, it appears they are having some success, in that the homeless people they are housing actually are looking forward to living in the new units and the people who have already been placed are enjoying their time.

Donnelly then takes the group to one of the apartments, a one-room efficiency where Lester Howell lives. Howell's small apartment includes a bed, a couch and a TV. It's not fancy, but Howell says he likes living here, where he can come home and be in peace.

Believe it or not, I actually think this is pretty promising... that the people they're helping actually want to be helped. From my experience and from what I've read on the subject, I'm always afraid that some chronically homeless people will not like living in an apartment once they realize it usually comes with having to follow rules. That might sound paternalistic of me, but I also think it is true.

But, the criticism levied against the program is the same one I voiced earlier:

The executive director of the Minnesota Coalition for the Homeless, Michael Dahl, said the state shouldn't focus its efforts only on the chronically homeless, when many people simply need a place to stay for a short time. Dahl helped create the state plan, and said it does a good job of trying to help a narrow segment of the homeless population. But he doesn't want to shortchange people who could end up long-term homeless.

"What about the new people that are becoming long-term homeless or folks who are just falling into homelessness and are in dire need of some support so they don't get to that point?" Dahl asked. "And I want to make sure that this plan has the components to make sure people don't become long-term homeless."

Dahl said that means that state also needs to fund transitional housing and prevention programs. Some DFLers point out that under Gov. Pawlenty's leadership, the state has cut some health care and chemical dependency programs that help people on the verge of homelessness.

An ounce of prevention is worth a pound of cure. Governor Pawlenty is admirably taking a business model approach to solving this problem by developing metrics and benchmarks, and then measuring the program's results to see if the plan is working or not. I like that. But don't forget the people who aren't homeless yet who just need a little push. If we let them down now, we'll have to carry them later, which will sink the plan in the end.

Contradiction?

Astute readers no doubt perceived a contradiction between my last two posts. In the first, I said I had issues with the program to put homeless people in their own apartments. In the second I said that programs to prevent problems instead of treat symptoms were great ideas and would save us money in the long run. So why don't I like the program in Denver that gives the chronically homeless an apartment of their own and a caseworker?

Part of it is a marketing problem. In Denver, this is being billed as a way to end homelessness. Unfortunately, I do not believe it is possible to end homelessness merely by helping people once they have become homeless. When I was working in outreach to homeless teens (many of whom were chronically homeless) in Boston, what we learned very quickly is that the people who become chronically homeless were abused in foster care as children, had parents who were drug addicts, or both. This is exactly why the program in Ohio appeals to me so much. It gives help to parents before they become drug addicts and lose their children to the system. It helps kids before they run away from home and turn to prostitution and drugs to survive on the streets. Unless you can help people before they become chronically homeless, there will be no ending homelessness. Another new crop of people will show up the next year, and the next, and the next.

But what do you do with people who are already homeless? In that sense, I think this is a good solution. Many of the people Gladwell cites in his article racked up tens or hundreds of thousands of dollars in hospital costs that may be avoided by keeping people in apartments. Homeless people have been known to get arrested on cold days so they can escape to the warmth of jail instead of being exposed to the elements. These are extraordinarily inefficient ways of spending money on homeless people. In that sense I do like the program, but it has to be part of a comprehensive system. Shelters are still important, they must be maintained. A greater focus must be placed on preventing chronic homelessness, not just housing those who already are chronically homeless. Finally, we must accept the reality that many people simply do not want to be what we dogmatically consider "a productive member of society". They want to be homeless and live on their own terms. The principles of compassion say that we should take care of these people to the best of our ability, even if it never saves us money in the long run.

One final note. In Gladwell's piece, he focuses on an anecdote of "Million-Dollar Murray". Murray was an alcoholic homeless man who cost the local Reno safety net over $1 Million over his lifetime in prison and hospital costs. However, when he was put in a program with a case manager, he stopped drinking and was able to hold a job. Until, that is, he graduated from the program and was sent to live on his own. He quickly regressed, quit his job, and went back to drinking a fifth of vodka a day. He is the archetypal success story Gladwell presents in his article: a very nice man who just had some problems and needed to be taken care of. The program in Denver is designed to help people like Murray. Unfortunately, as the article points out many times, Murray was unique in his friendliness and his responsiveness to compassion from others. If all homeless people were like Murray, the program in Denver would be a huge success. Unfortunately, as Gladwell goes to great pains to point out, most homeless people are not like Murray. To expect them to be like him is unrealistic and may be the single biggest obstacle to this program's success.

Ultimately, this program will not end homelessness by itself. Because Americans have an instinctive negative reaction to giving people something for nothing, and because this program will not end homelessness, my main fear is a backlash which will push homelessness even further into a "black hole" political issue. The American people give projects like these one chance a generation (it's been since the mid-1980s since homelessness was a front burner issue), so they have to succeed.

Gladwell's Hockey Stick and Homelessness

One problem with starting a blog in April, 2006 is that there's over a decade's worth of internet material out there that I have yet to comment on. A couple of months ago Malcolm Gladwell (the world-famous and completely brilliant author of Blink and The Tipping Point and a writer for the New Yorker) wrote an article called Million-Dollar Murray: Why problems like homelessness may be easier to solve than to manage.

His main point is that we are conditioned in our society to view everything in a bell-curve distribution, but sometimes a hockey-stick curve is more appropriate. In other words, we tend to think everybody contributes roughly equally to social problems, but often it's a few bad apples doing a significant piece of the damage. This kind of distribution is called a Power Law distribution. Anybody familiar with healthcare policy is already familiar with this concept. In healthcare, roughly 15% of the population uses 75% of all healthcare services.

Gladwell begins his analysis with the observation that the same is true for homelessness:

In the nineteen-eighties, when homelessness first surfaced as a national issue, the assumption was that the problem fit a normal distribution: that the vast majority of the homeless were in the same state of semi-permanent distress. It was an assumption that bred despair: if there were so many homeless, with so many problems, what could be done to help them? Then, fifteen years ago, a young Boston College graduate student named Dennis Culhane lived in a shelter in Philadelphia for seven weeks as part of the research for his dissertation. A few months later he went back, and was surprised to discover that he couldn't find any of the people he had recently spent so much time with. "It made me realize that most of these people were getting on with their own lives," he said.

Culhane then put together a database—the first of its kind—to track who was coming in and out of the shelter system. What he discovered profoundly changed the way homelessness is understood. Homelessness doesn't have a normal distribution, it turned out. It has a power-law distribution. "We found that eighty per cent of the homeless were in and out really quickly," he said. "In Philadelphia, the most common length of time that someone is homeless is one day. And the second most common length is two days. And they never come back."

The next ten per cent were what Culhane calls episodic users. They would come for three weeks at a time, and return periodically, particularly in the winter. It was the last ten per cent—the group at the farthest edge of the curve—that interested Culhane the most. They were the chronically homeless, who lived in the shelters, sometimes for years at a time. Many were mentally ill or physically disabled, and when we think about homelessness as a social problem—the people sleeping on the sidewalk, aggressively panhandling, lying drunk in doorways, huddled on subway grates and under bridges—it's this group that we have in mind. In the early nineteen-nineties, Culhane's database suggested that New York City had a quarter of a million people who were homeless at some point in the previous half decade —which was a surprisingly high number. But only about twenty-five hundred were chronically homeless.

It turns out that these few chronically homeless people account for the vast majority of total costs of homelessness to the system. Therefore, he advocates setting up an intensive care unit for the few chronically homeless people, giving them case managers at a 10:1 client to case manager ratio, and even giving them their own efficiency apartment. This is supposed to save the system money because an apartment is much less costly than the several emergency room visits these chronically homeless people make per year (which cost hundreds of thousands of dollars to local hospitals). They're trying it right now in Denver. The goal is to end homelessness, not just keep treating it.

I have a few problems with this approach. First of all, the 80% of the people who only stay in the shelter one or two days still need a shelter to go to. What happens to them if shelters suddenly become unavailable because all of the funding for homelessness is going towards this new program? If there is no safety net of soup kitchens and shelters, do the 10% who are periodically homeless then join the 10% who are chronically homeless? Or, if they keep shelters open to prevent that, are they still saving money over the old system?

Also, just because these people are given case managers and apartments doesn't mean they suddenly are able to kick the rampant addictions which got them to this point in the first place. Now, instead of being on the street while they drink their fifth a day, they have an address to direct the ambulence to when they need to be picked up for detox. I do not say this to be cold-hearted, but it is a reflection of the reality of chronic homelessness.

Lastly and most importantly, there is no guarentee that the chronically homeless even want to be off the streets. Where is the evidence that they want to be a part of society? Many homeless people actually prefer being homeless, as difficult as it is for us to believe. They would rather have no rules and be on the street than live in an apartment with a list of policies to follow. The program in Denver only gave apartments to people who wanted to be a part of their new program, so they at least thought they wanted to be off the streets, but what if they change their minds? Gladwell does concede that a limitation will probably be the program's intended beneficiaries being non-compliant with the treatment. However, it seems to me that it might have been a good idea to check with the homeless to make sure you're providing what they want before you spend millions of dollars giving them what they may not want. In summary, it still seems like homelessness will never be solved, it will always be treated. But this program may be a good piece of an overall framework that treats the problem on several fronts and allows the homeless to live with as much dignity and freedom as possible.