Think outside the prison

As the coronavirus surged in the United States, so did homelessness. Thousands of tents and makeshift refuges now crowd underpasses, parks and city sidewalks. These encampments lack reliable sources of clean water, sanitation and power, and are indistinguishable from some of the poorest living conditions in the most destitute places in the world. They are also disproportionately inhabited by people who suffer from mental illness and addiction, and who regularly cycle through the criminal justice system.

For many observers, it is difficult to align a fundamental belief in basic equality with a daily, public reminder that a growing number of people are navigating the inhumanity of homelessness. There are others who are less moved by the social injustice but have a NIMBY -- not in my backyard -- dislike for how homelessness impacts their property values, sense of personal safety and community aesthetics. In response, state and federal leaders focused almost entirely on affordable housing, including free or reduced-cost, short-term shelter during the pandemic.

Long before COVID-19, affordable housing was in precariously short supply in many areas of the nation. Yet, for a large percentage of the homeless population, this is an inapposite solution. There is a critical connection between mental illness, addiction, prison reform and homelessness -- all of which have been exacerbated by the pandemic. For those who are caught in this cycle, without significant structure and support, including inpatient, mental-health and addiction treatment, affordable housing will not pave the way to sobriety, mental stability, job security and independent living outside of prison.

Because there is a lack of funding for residential facilities, for decades hundreds of thousands of mentally ill and addicted people have been "housed" in American jails. But in recent years the U.S. sought to reduce incarceration rates and -- consistent with that policy-shift -- decreased prison funding. This trend was followed by a pandemic that caused the early release of many inmates who could not be safely socially distanced in prison. The impact is that there are now fewer "beds" available in American prisons, funneling many mentally ill and addicted people into the streets.

The United States is on the precipice of passing the largest infrastructure-focused budget in a generation. Now is the time to think outside of prison and create dedicated inpatient facilities needed to treat the growing population of people who are mentally ill and addicted in America. These investments -- which will serve some of the most vulnerable, underserved and disenfranchised among us -- are economically and ethically sound and will significantly and permanently reduce the United States' homeless population.

To implement a sustainable solution, decision-makers need to understand the current state of mental health and addiction and why so many people with those conditions are either in prison or living on the streets. According to the U.S. Department of Health and Human Services, mental disorders are among the most common causes of disability in the country. In 2018, 19.1%, or 47.6 million Americans had a mental disorder. Approximately 4.6%, or 11.4 million people suffered from a serious mental illness, meaning a diagnosable mental, behavioral, or emotional disorder that substantially interferes with one or more major life activities; these include bipolar disorder, major depressive disorder and schizophrenia. The same year, 20.3 million people aged 12 or older had a substance use disorder, primarily addiction to alcohol or drugs, including opioids and heroin. The Substance Abuse and Mental Health Services Administration reports that almost 30% of people with a serious mental disorder also have a substance use disorder. In 2018, a year before the pandemic, that meant more than 3 million people or 1.3% of all adults in the United States had these comorbidities. Early studies suggest that social distancing and the isolation of quarantine over the last 21 months have accelerated drug and alcohol abuse, caused relapse among many people who have had long-term sobriety, and have increased anxiety, severe depression and other serious mental health conditions.

For six decades, prisons have been the de facto "shelter" for both populations, serving not only a penal function but as a source of food stability and housing, and as an ill-equipped surrogate for inpatient mental health care and substance abuse intervention. Defunding mental health facilities and deinstitutionalization of psychiatric patients began in the 1950s. Civil rights concerns regarding inhumane conditions at some psychiatric hospitals, the belief that many mentally ill patients would benefit from less restrictive environments, and the desire to reduce taxpayers' costs for long-term psychiatric care, all contributed to a massive reduction in long and short-term psychiatric placements for mentally ill patients. By 2016, the U.S. had eliminated more than 96% of the nearly 600,000 mental health "beds" that were available in the 1950s to treat patients with serious mental illnesses.

Inpatient addiction treatment has never been prevalent in the United States, and for most of the 1800s was focused on providing a location for alcoholics to "dry-out." By the late 1800s and early 1900s, a modest number of treatment facilities were available for affluent people who were addicted to alcohol and the accessible drugs of the time including morphine, opium, heroin and chloroform. As drug addiction grew -- and with it an expanding array of options, predominantly cocaine, LSD, PCP, amphetamines and prescription pain killers -- what few residential treatment options were available through the 1970s diminished as the federal government shifted control to the states and insurance companies began to exclude coverage for inpatient addiction services. American politicians reflected the growing sentiment that drug and alcohol abuse, and its attendant societal costs, had become untenable.

This was the backdrop for the change in U.S. criminal justice policy that steeply increased the country's prison population for nearly 30 years starting in 1980. Until the 1970s, the incarceration rate in the United States had been relatively stable for decades, running at about 100 inmates per 100,000 people. This was roughly the same as Canada and below that of numerous other countries including Austria, Australia, Finland, Poland and the USSR. The War on Drugs that began in the 1970s manifested in legislation and criminal sentencing guidelines that caused imprisonment rates to skyrocket. By its peak in 2008, 2.3 million people in America were incarcerated, or about 1,000 out of every 100,000 people. While the U.S. had only 4.4% of the world's population it had nearly 25% of the world's incarcerated people with almost half of the federal prison population serving time for drug-related crimes.

Bipartisan support for criminal justice reform gained momentum after 2008. At $75 billion, the annual cost of "corrections" was unpopular among taxpayers. The United States also no longer seemed willing to double down on criminal justice policies that incarcerated a profoundly disproportionate percentage of people of color and also imprisoned people at a far higher rate than any other country in the world, including countries where the U.S. had active military alliance operations, such as Afghanistan and Iraq.

By the end of 2019, the United States reduced its incarcerated population by 12% to 2.1 million, in large part by decriminalizing, not charging, or not confining people for low-level drug possession offenses. Then COVID-19 arrived. In the interest of reducing the spread of infection for both incarcerated individuals and prison staff who could not easily be socially distanced, in the first seven months of the 2020 pandemic the U.S. decreased its imprisoned population by another 14% to 1.8 million people, the largest annual drop in its history. Of those 300,000 released in 2020, statistically nearly 50,000 -- primarily those with mental illness, substance use addictions, or both -- experienced homelessness in the year prior to their conviction. Like the tide, there is a steady flow between homelessness and incarceration. Upon release, most former inmates have no savings, limited education and literacy skills, few job prospects and the stigma of a criminal record. Once someone has been incarcerated, that individual is at least 10 times more likely to be homeless when they are released from prison. Roughly two-thirds of people who are homeless following incarceration are convicted again within a year.

The judicial branch sits at the junction of these overlapping and intersecting roads.

Judges play a pivotal role in the lives of people who have severe mental illness and addiction as they cycle between homelessness, arrest, sentencing, incarceration and release. Over the last decade, judges have had fewer practical or effective options for the placement of individuals who regularly find themselves mired in the criminal justice system. The collateral damage of the pandemic is the acceleration of housing insecurity that has left the judiciary with an exponentially larger problem and fewer solutions.

Many states now have a range of programs or specialized courts (including Veteran's Court, Drug Court and Mental Health Court) to address people with these and other struggles who have been criminally charged. Regardless of which court is involved, judges only have three general sentencing alternatives that ensure this population will be housed and potentially treated: inpatient mental health treatment, inpatient drug treatment, or prison.

As of 2018 the total number of residential beds for people with serious mental illness was approximately 170 thousand, enough to serve about five% of those needing treatment, all but closing the door to judges utilizing that option. Only 10% of the 21.2 million people with substance use disorders in 2018 received treatment of any sort, with just a fraction of those receiving the minimum three-month residential treatment that is necessary, according to the National Institutes of Health and various scientific studies, to effectively address the most prevalent and pernicious addictions in America, including opioids. As a result, inpatient addiction treatment is another sentencing door that is often closed to judges. For those with serious mental health disorders, addiction, or both, the revolving door to prison was wide open until 2009. That door is now slowly shutting and, like the other two, has not been replaced with any alternative that judges can use to ensure that this population, once convicted or diverted, is housed. The only door that is left, is the one that leads outside.

There are more than a half a million people experiencing homelessness throughout the country, with the largest numbers in major metropolitan areas including in California, the District of Columbia, Massachusetts and New York. For those individuals who are also mentally ill, addicted, or both, the United States needs an offensive strategy that eviscerates homelessness and prevents this population from interacting with the criminal justice system in the first instance. When these individuals commit crimes, judges should have sentencing options that work synergistically with that strategy to ensure that the cycle of homelessness does not return. Those choices should include scientifically sound treatment that would eventually allow many of those individuals to productively participate in society. The United States must also incorporate legitimate placement options for people with acute mental disorders, some of whom may never be able to independently live in a non-supported environment outside of a residential psychiatric facility.

Right now, the legislative and executive branches of the United States and numerous individual states are considering how to invest an unprecedented amount of money that will likely be injected into the economy. There are countless public health, education, environmental, employment, infrastructure and stimulus priorities vying for these dollars. But the people who are severely mentally ill and addicted do not have political action committees or lobbyists to advocate for their interests and compete for funds. Without a seat at the crowded table, these people -- who were some of the most dramatically impacted by the pandemic -- will be left behind in the economic recovery and the United States will continue to have a homelessness crisis. If instead, the legislative and executive branches choose to dedicate some of this funding to develop an economically sustainable network of services to address the nexus between severe mental illness, addiction and criminal justice, the prospective long-term societal upsides are enormous. With the partnership of the judiciary, the United States has the potential to simultaneously reduce the number of people who are incarcerated and who are homeless -- for good. 