JOSH: Hello, and welcome to Clearer Thinking with Spencer Greenberg, the podcast about ideas that matter. I'm Josh Castle, the producer of the podcast, and I'm so glad you joined us today. In this episode, Spencer speaks with Kevin Adler about homelessness, mental health, and affordable and accessible housing.

SPENCER: Kevin, welcome.

KEVIN: Spencer, it's good to be with you. Thanks for having me.

SPENCER: I posted about the fact that I'm having someone who works with homeless people on Twitter and on Facebook, and the amount of questions that I got for you was tremendous. People are so interested in this topic. And I think it's because many people live in big cities like New York or San Francisco. They see homeless people all the time and they wonder: what can they do to help? Why are there so many homeless people? Why does it seem like so much money is going to this problem, but it doesn't seem to be improving? So I'm really excited for this conversation. There's so many questions that I have.

KEVIN: I can't wait to answer every single question perfectly on the issue of homelessness and by the end of this, have all the answers for the listeners. Let's set that expectation at the outset, right?

SPENCER: [laughs] Well, look, all you have to do is tell us your opinion, and I'm sure it'll be informative. Obviously, it's an incredibly complex question. Why don't we start with the scale of this problem? So I live in New York City. I've heard that there are something like 85,000 homeless people in New York City. Does that sound about right to you?

KEVIN: Sounds about right, yeah. There are a lot of folks who are invisible that we don't see as homeless that are right now under... The process for counting people experiencing homelessness uses what's called the PIT Count, which is the Point-in-Time Count, where literally every January, on a cold night, canvassers will go around the cities all across the country and, with clipboards and paper usually, count one by one: there's a person experiencing homelessness, there's a person experiencing homelessness. And that's the number eventually that's used to determine the HUD estimate. Right now it's about 600,000 Americans experiencing homelessness. But as you can imagine, it tends to be a woeful undercount. Folks who are doubled up, tripled up in someone's apartment, people who are couchsurfing, people who are maybe in vehicles and tunnels, in other spots not meant for human habitation, they tend to not be counted or seen as people experiencing homelessness in the same visceral way that walking by someone on the streets and seeing them panhandling might be. So I don't know the exact number in New York City. But if it's a PIT count number, we can be pretty confident that that's probably an undercount.

SPENCER: I noticed that you refer to them as 'people experiencing homelessness,' whereas I said 'homeless people.' Is the terminology 'homeless people' one that you avoid?

KEVIN: The language we use is pretty significant. And in the ten years that I've been on this journey coming from not knowing a thing about homelessness other than having had an uncle who was homeless — and happy to share more about that story in a moment — to today. I have learned that one of the key issues that really feels important to talk about early in this conversation is that we see them as them, not really part of us. And so using person first language, but not just in a kind of procedural way that feels a little clunky, actually just seeing the experience of homelessness not as a permanent identity as perhaps we would never look at each other as 'housed people,' even though we hopefully have housing, and stable housing at that. But we've defined an entire group of people by their lack of one physical need. And so in my book which came out recently — it's called "When We Walk By" — one of the key ideas that we put forward in the book is the importance to get past us versus them thinking, to use person first language and see people experiencing homelessness, not as a monolith, not as the homeless, because if we see folks in a very narrow grouping, I think it actually limits our ability to come up with solutions, and to really see this problem in its complexity and its nuances that exist.

SPENCER: I'm going to feel like a total jerk if I now call them 'homeless people.'[laughs]

KEVIN: [laughs] I was just thinking, "Does this shift the entire conversation, at least for the next hour?"

SPENCER: I will try to refer to them as 'people experiencing homelessness.' But I will probably slip up, so I'm just going to flag that.

KEVIN: 'Unhoused neighbors, unhoused friends.' Yeah, it's not meant to be... I'm not going to tsk tsk you, I promise. Because I do know it can be a little clunky, but I think it's just taking an extra beat to reflect on the language we use. Because actually, here's a stat. Can I give you my little science stat of... I'll have more, but here's the science one: neuroscientists at Princeton and Duke have found that the part of our brain that activates when we see a person is called the medial prefrontal cortex. That part of the brain has been found not to respond when we see someone that we perceive to be in an extreme outgroup in our society, and that includes people experiencing homelessness. And so the implications of that is that we're not actually neurologically processing a person experiencing homelessness the same way that we would a housed person. A few years ago, the New York City rescue mission did an experiment, where they had individuals dress up to look homeless as unsuspecting members of their very own families walked by. And in each instance of this experiment, not a single person recognized their own mom or dad, brother or sister, son or daughter, husband or wife, on their path to work, to home, to wherever. And so I think, to get past... It's not just a matter of language. At a very fundamental neurological level, how our brains are processing people experiencing homelessness, it's much more akin to an inanimate object or an other rather than a human being. And so a small gesture towards that is the language, but I think it does run a lot deeper than that. And that's worth a conversation as well.

SPENCER: Yeah, I notice how people just avoid even looking at people experiencing homelessness as I do myself when I feel like maybe they're gonna ask something from me, or maybe I'm gonna feel guilty if I look at them but then don't help them. And you become kind of immune to it in some sense, where you're just trying to close yourself off. And it reminds me of one time, I had dinner with an acquaintance and as we were leaving, she saw someone begging on the side of the street, and she went up to them. And she said, "I am so sorry but I don't have any change on me right now." And she spent five minutes talking to them. And it was so surprising to me just because I'm so used to everyone not engaging with them and ignoring them, that it was actually like, wow, she really engaged with this person.

KEVIN: I think it comes from a combination... Hey, kudos to your friend. That's amazing. And one takeaway from this conversation is perhaps being able to do that or being aware of that, but it's not meant to be, "Do it all the time," or, "Every single person you see, sit down and have coffee." That's not realistic. But I do think taking a moment to think about both how maybe we don't engage, in part because we don't know what to do, but I think also in part because we may not like what we see, in that we may recognize more of ourselves in the person than we realize. When I've gotten closer to my neighbors experiencing homelessness, and I hear the reasons a person became homeless, from health issues, cancer-induced financial toxicity, job loss in the Bay Area... One out of every three people who become homeless have attributed it to some form of relational brokenness. So it could be an argument with a loved one, a death in the family, a divorce, separation, falling out, people are doubled up, tripled up, there's not as much wiggle room, things are more tense. So I do think there's evidence that I've experienced, and then there's research that backs it up. There's a study Stanford did a few years ago, researchers at Stanford, where they found that there were Salvation Army bell ringers, and the bell ringers were stationed in front of one of two doors. And they were observing people to see who went through the door, A versus B — without the bell ringers, and then with the bell ringers — who would go purposefully to the other door, and what's the delta between choosing which exit you go through based on the presence of the bell ringer, because maybe you don't want to be bothered. And then what happens if they're engaged with another bell ringer who's there and they have their empathy tackled? And the gist, the takeaway of this experiment was basically finding that people disengage as we might expect; they purposely go to the other door. But when confronted with a bell ringer and when asked to give and help, they felt compelled to do so. And the takeaway was, well, it's not that we disengaged because we don't care. It's because we know as people, we're capable of caring so much that if we take the time to actually get up close and personal, we'll either feel obliged to help, or we'll feel obliged to help and then find that maybe there's nothing we can do and feel awful and helpless, and have our empathy crushed. So I think that applies with our neighbors experiencing homelessness when we walk by. I don't think it's because of callousness. I think it's because of our empathy actually, our desire to want to help but being unsure of what we could possibly do that would make a difference.

SPENCER: That makes me think about how one of the really common themes in my listeners' questions that they want me to ask you was around what we can do to help. Let's say you want to help people who are experiencing homelessness, and you see someone begging on the street. Is it better to give them money directly, or is there something else you should do with that money if you want to help them?

KEVIN: Yeah, it's a great question and it's one that I have certainly struggled with myself. I often don't give money directly to individuals on the streets, but I try to give things like socks, which are one of the number one requested items on the streets; I always carry some socks with me. We have cards for my nonprofit, Miracle Messages, which we distribute offering our services. But there's actually a passage in my book that I think really gets to the heart of this question of whether to engage and whether to give money or something else that I wanted to just read, if that's okay, if I can pull it up for a sec.

SPENCER: Absolutely, please do.

KEVIN: Alright, so this is the beginning in the first pages of Chapter Four in the book, When We Walk By," on paternalism. And just to cue this up, the very beginning of the chapter begins with a man named Ronnie Goodman. Ronnie was a friend of mine who spent years experiencing homelessness, who's on the streets in San Francisco. He had been released from San Quentin, and was released basically to the streets. And there really is a revolving door between the criminal justice system and homelessness. And Ronnie was pretty unique as a human being because he was a fabulous artist. His artwork was very well known in the community. He was about to have his work featured in a gallery in New York just before he passed away. And then he was also a marathon runner, and did running on the streets. And one time in a conversation, Ronnie and I were chatting, and I was asking him about his housing status, and what I could do with anything to help him get housed. And he said, "Well, you know, Kevin, I actually have housing available to me if I want it." I said, "Well, Ronnie, what are you doing then? Why are you still sleeping in a tent under an overpass? Why aren't you taking advantage of that housing?" And very patiently, he looked at me and said, "Well, the housing is in a building in a neighborhood in San Francisco where drugs and alcohol are present 24/7. And I've had an addiction history. And I know if I go back into that housing unit, I'm going to relapse and die. And so I'm waiting for a few years. I'll be eligible for senior housing and hope to get off the streets through that, through something that isn't essentially causing potentially more harm than good for me." And I heard this and it really shifted my own understanding of the question I had asked, because I realized that immediately when he said, "Well, I have housing available to me but I'm not taking it," I immediately got very judgmental like, "What are you doing? How could you make that decision?" And then you actually listen to what the logic was behind it, and you're like, "Well, that's not such a bad decision." He made a pretty informed decision there. So I want to contrast that, that's the lead-in. Its heading is, "Has a homeless person ever refused food you've offered them?" If someone did not know the circumstances of Ronnie's situation and just heard that a person who was living on the streets of San Francisco had declined free housing that was offered to them, they might be confused, frustrated or angry. Perhaps they might use the story to affirm a pre-existing prejudice, assuming that Ronnie is yet another example of a person experiencing homelessness choosing to be homeless. Perhaps they might respond as Tanja did when a person experiencing homelessness refused a meal offer from her young son. She related the story in response to a question posted online which is quoted as this section's subtitle. So this is the time I did a search online; I can't remember what late night search terms I used to find this but it was on Quora. And this was in a post in response to this question, "Has a homeless person ever refused food you've offered them?" and here's what she said. Months ago, three of my children, my husband and I were at a taco Mexican grocery store. And a man who seemed very homeless sat outside with a sign that said, "I will work for food. Help, please, anything will help." So my nine-year-old wanted to help so badly. We ordered him two tacos with rice and beans and a coke and water bottle. The man seemed irritated and told my son, "No, I only want money." My son still tried to tell him to save it for later and keep it anyway. The homeless man refused, which absolutely crushed my son's big heart. I was so mad. I told my son, "See, some people just want drugs." We then just took the drinks and tacos home. It's been months since and neither he nor I have given any homeless person anything since. I tend to give out cold water bottles at lights but haven't been recently. Okay. So the reason I wanted to bring that up is, you hear the story and, of course, you read that and you're like, "Oh, you're jumping to conclusions. What an unfortunate lesson. There's probably many valid reasons why this individual may have not... Maybe they weren't hungry. Maybe they were diabetic, and all they saw was the Coca Cola. Maybe they were just wanting a hotel room for a night. Who knows? Or maybe, they were wanting to just use it for drugs and alcohol. Maybe that was the reason. But the point is, who knows?" And the more important question that I think doesn't often get asked, is not whether a particular individual experiencing homelessness offers a satisfactory explanation for declining a meal or whether they're going to accept our offer of charity, but why, at some level, do we feel entitled to make that assessment in the first place? As decent people, we don't want to do more harm than good. And there's plenty of research that's found that, when you give to panhandlers, the majority of the money is spent on food. In San Francisco, there's this massive survey and like 90-something percent of panhandlers said, "I use the money for food." Does that mean that every person is using it for food or housing or things that we maybe deem good and appropriate? No, probably not. But it also raises another question, which is, would we invite a similar level of interrogation to our decisions of what to eat, how we spend money, where to live, whom to date, whom are we interacting with like that? And I think part of the issue that I'm arguing in this book, is that there's a level of paternalism so endemic in the homelessness space, from homeless services to media coverage of this issue, to even unwittingly, how we engage our neighbors on the streets, that it's part of the problem and it limits the kinds of interventions and solutions and things we can come up with, like basic income. And we can talk more about that in a minute. But yeah, thanks for letting me do my Reading Rainbow best impersonation here with that story.

SPENCER: [laughs] I think that's a really interesting perspective. But could you unpack that a little more? What is it preventing or what is it stopping, that attitude?

KEVIN: The attitude that someone like Tanja might have, and perhaps some of us also, is it furthers this divide of us versus them. It furthers this sense of who the homeless are. It also keeps us from actually getting to know our unhoused neighbors as neighbors. So if you walk by and you see someone, and you just presume that, okay, they're gonna blow it on drugs, or alcohol, or whatever else it is, or they're choosing to be homeless, and this is a choice, and they're going to drive off in their Corvette to their nice house as a result — which, again, there's plenty of evidence that that's just not the case — we've not only dehumanized the person and created this worst case scenario stereotype that we've now clumped everyone we see who maybe matches a certain identity into, I think we've lost a little bit of our own humanity. As you saw on Twitter, people are really passionate about this issue. They care. They want to help. They're frustrated. Things are not working, clearly. It's very hard to feel anything but awful about the current situation where people are living and dying on the streets. However, the solution isn't to further distance ourselves from our unhoused neighbors. We've already done that. That's been the case from city ordinances that make it essentially illegal to be homeless: one out of every two cities have anti-camping, anti-sleeping, anti-loitering, anti-feeding. People have been arrested for literally feeding people experiencing homelessness, where we are very quick, if there's a conference in town or a major event, to push people out to the outskirts without any kind of housing or stability offered. But it never actually gets to the root of what the person is going through. What is their barrier to housing? Is it simply a lack of enough housing units? Perhaps, that's part of it. Is it that they have a housing choice voucher and no one's accepting it? They can't find a landlord who's willing to give them a chance in an interview. Is it a health issue, where they're in a medical shelter bed and not able to get off the streets or into any kind of stability because they're reliant on this medical respite bed while they're going through treatments? So if there's 600,000-plus people experiencing homelessness on any given night, there are 600,000-plus nuances, contexts, stories of why the person became homeless, and why they're still on the streets. And I think it's incumbent on us as housed people to do whatever we can to get as close to our unhoused neighbors to understand what those reasons are. And I think it's not just to go up to everyone, give them a hug and sit down and listen to their story. I think we're talking about a type of homelessness that is very visceral — unsheltered chronic homelessness — where there's often a confluence of drugs and alcohol substance abuse. And that's a very visible and upsetting form of homelessness. But again, there's a majority of people who are experiencing homelessness that we would never identify as such. And I think it is critical that we find ways by going to shelters, soup kitchens, volunteering. Organizations like Miracle Messages, we have a phone buddy program. We have volunteers that connect with our unhoused neighbors. We do outreach. I think it's critical for us to get a little bit closer. It doesn't have to happen through your walk to work and school. And again, I choose not to give money on the streets because there are questions that I have of whether that's the best thing, but I do find something to try to give out to engage as a conversation starter.

SPENCER: Let's step back for a second and take a bird's-eye view on the issue of homelessness. When you look at a place like San Francisco or New York, a lot of what people are referring to when they use the word 'homelessness' is what's visible to them, like the people they actually see on the street. How representative are the people you actually see on the street when you're in Times Square, or a big area where you might see homeless people? And how many of the people that actually don't have housing are actually quite different from the situation that you might see most visibly?

KEVIN: It depends on the city and it depends on the location. In California, we have one of the largest unsheltered populations in the country. And I think nationwide, the numbers are almost neck and neck based on the HUD definition of homelessness where 600,000 Americans experiencing homelessness on any given night, around half are unsheltered. That could be on the streets, it could be living in a vehicle, and about half of them are in some kind of shelter of some sort. But that's again using the HUD definition, which is very narrow and limited in its scope. When we look at the Department of Education's definition, which includes couchsurfing, doubled up, tripled up, youth homelessness, we estimate about six million people experienced homelessness at some point over the course of the year. The vast majority of those individuals are sheltered or doubled up or tripled up, out of sight, out of mind. And that is a major group that we talk about in the book. Because the way I analogize it that hopefully is helpful: if you're in college, you're a first-year college student and it's Friday night, it's Saturday night. You want to see your friends, you want to go out, you want to socialize. And you receive an invite and you maybe go to a frat party or a sorority party, and you go there once or twice. And you're standing in a backyard with a red cup, and music's blasting, and you're just like, "Oh, my gosh, get me out of here." And maybe for the first few weeks, you're kind of like, "Oh, my gosh, is this the college social scene? I don't know if this is the right place for me." Or maybe you love it, but it may take a few weeks or a few months or maybe a semester or two to realize that the majority of people on campus, depending on the college you go to, but in general, they're probably not going to a backyard drinking out of a red cup every Friday, Saturday night. But it's this visible minority that takes a lot of the energy. A lot of what we think of when we think of 'partying in college,' it's standing in the backyard with a red cup. It takes up a lot of the mental bandwidth. But there's a larger majority of people who are going to the movies, having dinner parties with friends, going to whatever art institute or going to a lecture, walking around campus playing frisbee golf (as I would do), whatever it is. But we don't see it that way and it takes spending some time getting used to it. So in a way that's kind of what it's like for our neighbors experiencing homelessness. There's this incredibly visible minority in most communities, of people who are unsheltered, chronic homelessness, where untreated substance abuse issues. untreated mental health issues are as prominent as can be, and they deserve as much empathy, compassion, treatments, support as we can offer. And they're often the ones who cost society the most in terms of maintaining someone on the streets: sanitation, emergency services, police, fire, $40,000 to $80,000 per person per year to maintain them on the streets, not to mention emergency room visits where you can have high utilizers of the ED, so not only in terms of finances, but emotional bandwidth, psychological bandwidth — our kids walking to school, walking home from work — that's a very visible segment of the homeless population. But it's not the entirety and it's not even the majority.

SPENCER: How big is that population, the really visible people that you're referring to?

KEVIN: Right now, half of all unsheltered people in the United States are in California. And it looks like the number in California is about 115,491. And then nationwide, it's 233,832. And again, that's out of about 600,000. So it's a little less than half and that's unsheltered.

SPENCER: I think that most people that I know, when they refer to (quote) 'homeless people,' they're talking about the people that they pass by every day that seem to live permanently on the street. And I think that's just a visibility thing, like you were talking about with colleges, right. So how big is that group as a percentage of homeless people in general, or people experiencing homelessness?

KEVIN: There's language that we use in the homeless services space between someone who's chronically homeless versus someone perhaps, who's an unaccompanied youth, or a veteran, a person in a family unit that may not be chronically homeless. So when we talk about chronically homeless individuals, that's really the group that I think is sometimes presumed to be all people experiencing homelessness. And by the numbers any given night, there's about 580,000 to about 600,000 people experiencing homelessness, and about one in five of those individuals are chronically homeless individuals. And it doesn't mean that one in five of people experiencing homelessness on any given night have some kind of severe substance abuse issue. There's research that's found that the mental illness rate among the 580-something thousand people experiencing homelessness is around 30%. Thirty percent of those individuals have some kind of mental illness rate.

SPENCER: Does that include substance abuse or is that separate?

KEVIN: No. And about half of those individuals have some kind of substance use disorder.

SPENCER: Okay, so maybe 15% then,

KEVIN: Somewhere in 15%,

SPENCER: Yeah, that are experiencing both substance abuse disorder and mental illness. Or does substance abuse count as mental illness from the point of view of this?

KEVIN: Yeah, they're interchangeable. And we talk about mental and behavioral health, which is really the broader grouping.

SPENCER: So 15% with substance abuse disorders. That number is actually quite shocking to me. I would have expected it to be much, much higher than that. I'm curious to hear your thoughts on that. Maybe it's just that my intuitions are way off here but, yeah, I imagine a lot of people would be surprised it's that low.

KEVIN: Yeah, about 82%, 84%, according to one survey of people in the general public attribute the causes of homelessness to some kind of substance abuse issue. And I think it's like 67% of people say it's some kind of mental health issue. And it's not to say that it's not a massive problem among people experiencing homelessness, but I think sometimes what gets lost is the difference between cause and effect around it. The cause of homelessness often could be an economic dislocation: job loss, relational brokenness, falling out, health issues, some of the things that we've talked about, domestic violence. The effect of experiencing homelessness, unstably housed, being on the street, or even in a shelter environment... Having been in many shelters in congregate settings as just a visitor. I would not wish an experience like that on my worst enemy. It's an awful place to be: in by 7pm, out by 7am, can't bring your partner, can't bring your stuff, can't bring your pet. You're in a room with people of all different situations, comorbidities that may or may not align with why you became homeless, what was your experience, So I think we look at the effect of being in such a, not only traumatizing, but unsafe, unhealthy situation, where the average life expectancy for unhoused neighbors is 30 years less than they would be if they're housed — we're talking 50 years old instead of around 80 — and there's a self- medicating that happens. And unfortunately, with the opioid epidemic, what it is with cities being way too permissible about what's happening on the streets, our neighbors experiencing homelessness are often the most susceptible and the most vulnerable to drug dealing, to narcotics on the streets, and then their lives are being lost. But I just wanted to add that nuance because it's, I think, tempting and reinforcing to these individual responsibility notions which again, even with addiction, it's a disease, it's a medical condition. It's not like I choose every day to take this substance that's not good for me. But it isn't a matter of the majority of people who are addicted to substances, it's not that that's what propelled them into homelessness, but that may be what's keeping them on the streets and making it that much harder to get into stable housing.

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SPENCER: Do you think that among the chronically homeless population, these numbers would be substantially higher, the 30% mental illness rate and the 15% substance abuse rate you mentioned?

KEVIN: Yeah, because among that population, that's where this issue around substance abuse and untreated mental health issues are concentrated. So yeah, within that chronically homeless subcategory, about one in five people experiencing homelessness on any given night... I don't have the exact numbers handy, but it's a much larger percentage of those individuals who do have some kind of untreated substance abuse issue or mental health issue.

SPENCER: That might help explain why people have such wrong intuitions because again, I think that they're often associating homelessness with this chronically homeless group that they're actually seeing on the street. And they're not thinking about that that actually is a relatively small percentage, about one in five of people experiencing homelessness broadly. And so their intuitions for the problem are probably way off.

KEVIN: Yeah. And it's interesting to think about what the implications of that are. But I certainly don't want to... I think what happens sometimes in conversations like this is, if someone's coming from a homeless services realm writ large, there's this kind of like, "Oh, things are getting better," or, "What you're seeing every day of people suffering, it's not so bad. Not to minimize it, but you don't see all the good work we're doing." I think a lot of that's bullshit. [laughs] People know their experiences and they know things have gotten worse on their blocks, in their neighborhoods. The drugs have gotten stronger. It seems like there's less effort to try to deal with this. And one of the more controversial things I call for in the book and talk about pretty openly is the limited but important role of involuntary treatment and involuntary holds. My opinion and my perspective on this has been heavily influenced by conversations with two groups: people experiencing homelessness, and their family members. And talking to individuals in both of those groups, especially family members. We get messages every day at Miracle Messages asking us to help locate their missing loved one who may be on the streets. It's no quality of life to be totally untreated mental health issues, untreated substance abuse issues, out of your mind, having all sorts of things happen to you. Such a low quality of life, unlikely for longevity. So I do say there's a role for treatment, and I think there's a lot of medical practitioners that are coming in and saying the same. The rub though, the challenge is, well, you have an involuntary hold, or you hospitalize someone, they're in the system, they're getting the support they need, but for how long? And what happens afterwards? Do you discharge them back to the same environment that they're in? Is there enough housing available to them? So I just wanted to, before we transition to the next topic, not come across as someone who's trying to say the emperor has no clothes. It's awful, what's happening on the streets. At Miracle Messages, we used to do street walks and we bring volunteers together to offer our services. We do family reunifications for people experiencing homelessness. We do a phone buddy program with volunteers and then we do basic income. We created one of the first basic income pilots in the US for people experiencing homelessness. We no longer do the same evening street walks in San Francisco in the Tenderloin that we used to because I can no longer feel that I can look a volunteer in the eye and say, "Your safety is pretty well assured." It's not to say that walking down the street talking to a person experiencing homelessness, you're going to have an issue. But I do think the conditions on the street writ large involving people experiencing homelessness — often as the victims of the crimes, not the perpetrators of the crimes — but just the prevalence of drugs, substances on the streets, it's gotten far worse. And I think there needs to be a lot more effort to crack down on what's happening on the streets in terms of people dealing drugs and whatnot.

SPENCER: For the rest of this episode, I'd like to focus on the chronically homeless group in particular, because while that is not even the majority of this issue, I think it is a group that is of a specially high interest to a lot of listeners, especially listeners that live in big cities, where it's really the chronically homeless that they are passing by in the street and, in some cases, they are feeling like they want to help or feeling like they can't help or feeling like that maybe risk is posed to them by these people. So I think that that is a group that is well worth digging into in this episode.

KEVIN: Sounds good. Let's focus our conversation there.

SPENCER: All right. So you have had so many experiences learning about the lives of people in this situation. One thing I just wanted to ask, could you maybe give us — obviously everyone's life is different and there's gonna be so many different stories — but I was hoping you could give at least a couple of stories that help us get a feel for how someone ends up in that situation, maybe scenarios that are relatively common?

KEVIN: Yeah, absolutely. I'll maybe share the first couple stories of how I got into this work, and then I can share another one more recent, if it's of interest. So storytime, let's do it. So my uncle was homeless for 30 years. He was a chronically unhoused individual and he suffered from schizophrenia. So in his case, as we were talking about, there's a larger percentage of folks who have some kind of untreated severe mental health issue among the chronically homeless individuals. My Uncle Mark was one of them. But, for me, I never thought of my Uncle Mark as a homeless man because he was just my beloved uncle, who remembered every birthday, always sent me a card every single year on my birthday, always signed — just Mark at the bottom — and was really the guest of honor at our Thanksgiving and Christmas dinner table. And growing up, we'd have a wonderful conversation with Mark and, if he was stable and on his meds and doing well, we'd have him over and we'd spend time together as a family. And then inevitably, my dad would drop him off and bring him back to Santa Cruz or he'd get on a Greyhound bus. And sometimes we wouldn't hear from him for six months at a time. And so, one of those times, the six months got longer and longer, and we ended up getting a phone call one day while I was in college, letting us know that Mark had been found deceased. He was, at the time, in some kind of transitional housing unit. He was by himself, age 50, which is about the average life expectancy of someone who's chronically homeless in the US. It was very, very upsetting, because he was just such a beloved member of my family. And so my starting point for this work a few years after that... We had the funeral service and I had a chance to visit his grave site with my dad. And we're sitting at the grave, and having this pretty rich father-son conversation about what life is like on the streets, and what Mark's life might have been like when he was on the streets, away from the dinner table from us. I started talking with my dad, and we were talking about his life, his memory. And I realized sitting there that the grave site just didn't really tell me any of this story of who he was, of this person that meant so much to me. Wanting to get close to our unhoused neighbors, I started out by basically walking the streets, going up to everyone I saw who was visibly homeless, starting a conversation introducing myself — "Hi, my name is Kevin. How long have you lived here?" — and asking some segment of folks who seemed like they wanted to engage if they'd be comfortable wearing a GoPro camera for an hour or two, and sharing their experience of what life is like on the streets. And the premise was basically: I just walked by you, you're still here, what's it like to be you? And so, over the course of a year, I had 24 individuals that I called 'homeless autobiographers' that basically volunteered for this half-thought out idea that I had of trying to build my own compassion for people on the streets, because when I walked by people, individuals who were chronically homeless, I didn't see them in the same way that I saw my Uncle Mark. I saw them as, as I put it now, problems to be solved, not people to be loved. And by seeing people as problems, I think it limited my own understanding of what they're facing. I didn't see them as someone's son or daughter, someone's brother, sister, some kid's beloved uncle or aunt. So I watched dozens of hours of footage collected over the course of a year, watched all the clips, and I'll share, Spencer, it really was heartbreaking to see what I saw. A few of the things that stuck out... So first, every single time a kid would walk by, you'd see the kid look at the person and want to engage and want to have a conversation, maybe tug on mom or dad's sleeve and say, "Why is that person on the streets?" and the parent half the time would let the kid kind of guide them, and then the other half the time, they'd almost scold the kid, pull them away. And it made me think. Is there something that we just intuitively know as children, that maybe we forget as adults of basic right and wrong? What's this wanting to get up close and personal and asking why is this person on the streets in this way? But the second real insight was, over and over again, people just totally ignored, overlooked, pitied, scorned, looked past; it's very dehumanizing to watch. And in one of the clips, I heard someone say something that really changed my perspective on this work. Very simple. They said, "I never realized I was homeless when I lost my housing. Only when I lost my family and friends." I never realized I was homeless when I lost my housing. Only when I lost my family and friends. And I thought, "This makes sense intuitively." What they said makes sense. But I've never heard any service providers and the organizations articulate this aspect of homelessness. Theoretically, if I could just walk down the street, can I just go up to every single person I see who's visibly homeless and ask, "Do you have any loved ones you'd like to reconnect to?" And maybe some percentage will say yes. And so 2014, December, I took a walk down Market Street, went up to everyone I saw who was visibly homeless in San Francisco, saw someone who was sitting there kind of talking to themselves, had a substance, a bottle of something to their side. Initially, I just walked by him and assumed, "Okay, there's no way this guy has any interest in having a conversation with me, let alone talking about family and social support." And I decided after walking by him that I should probably honor this goal I set, of talking to each person, went back, sat down, the person's name was Jeffrey, and started a conversation. He was really not giving me much time or attention. I was about to get off. He used one-word answers. And then I asked, "Do you have any loved ones you'd like to reconnect to?" And for the first time in the conversation, he looked me right in the eye and he said, "Well, my dad Harold, my niece and nephew, Josh and Rachel, my sister Jennifer, I haven't seen them in a long time." So I said, "Well, would you like to record a message to them?" I'm kind of winging it at this point, wasn't sure what to do. And he said, "Well, yeah, sure." So I pulled out my phone, hit the record button, recorded a video from him to his family, went home, posted the video on this Facebook group connected to his hometown. Within one hour, the video goes viral. It makes the local news that night. Classmates start commenting saying, "Hey, I went to high school with Jeffrey. I work in construction. Does he need a job?" "I work at the congressman's office. Does he need health care?" And in the first 20 minutes of the post, his sister got tagged. We got on the phone the next day and it turned out that Jeffrey had been a missing person for 12 years. This is broad daylight, downtown San Francisco, a few days before Christmas. So that was my starting point in this work, Spencer. At that point, I started doing this work full time. And it's what became Miracle Messages because I knew Jeffrey wasn't the only one, and this shouldn't be happening. We shouldn't have, in some ways, a group of people that are that visible in our society, but perhaps that invisible and disconnected from family, friends, community, social support, social capital, that could really perhaps play a role in helping them get off the streets, what we call in the book and what I would talk about as 'relational poverty' as an overlooked form of poverty.

SPENCER: I suspect that one thing that makes it harder for people to empathize with people experiencing homelessness, especially the chronic homeless population is, they may think to themselves, "Well, even if I lost my job, what I would do is, I would call friends. And if I didn't have any savings, I would sleep on a friend's couch and work really hard to find another job and then I'd get back on my feet." And so they may find it difficult to really see themselves in that story. And having had all these conversations, can you tell us a bit about how someone goes from having a home and a job to ending up chronically homeless?

KEVIN: Yeah, that is such the right question. It's hard to relate to. It's almost inconceivable, because, in the times that I've had challenges in my life — I lost my mom to breast cancer when I was 23 — a network of friends helped pull me through a very tough moment in my life. I had my dad and my brother, and they were supportive. And my college at the time, they gave me a leave of absence. So how does someone end up in a situation like that? I look at — and I think it needs to be centered in this conversation — not just this question, why are there so many people experiencing homelessness? But right now in the US, one out of every two Americans are a paycheck away from not being able to pay rent, and 47% of people self-report not knowing where they'd get $400 for an unexpected emergency. So given the numbers, half the country being one paycheck away from not being able to pay rent, why aren't — to your point — tens of millions of people experiencing homelessness? Why isn't half the country falling over the edge in homelessness? And what we're finding is family, friends, community, church, synagogue, mosque, informal economy...just basically what you were talking about; you have friends, networks, you double up or triple up, you get a little bit of a loan, a little bit of cash support, your networks. Problem is, for people experiencing homelessness — chronic homelessness especially — perhaps they didn't have that. Perhaps their family could have been part of the problem, not part of the solution. Domestic violence is a major cause of homelessness, especially for women, and often, there's shelters just for women with small children. LGBTQ youth constitute about 9% (estimated to be about 9%) of the general population in the United States, but over 40% of the unaccompanied youth homeless population, and often because the family environment may not be safe; it may not be helpful. And it's not just to say chronically homeless individuals just don't have good families. Oftentimes, a person experiencing chronic homelessness is coming from a family which may not have the economic resources to get by, may be similarly depressed, not that much better off than a person who's chronically homeless. And for one data point that really, I think, emphasizes this, do you know what the number one predictor is, the number one variable to look at, to determine the likelihood of someone experiencing chronic homelessness? What's the number one correlated factor? Do you want to take a guess?

SPENCER: You mean before they experience it, or once they've experienced it?

KEVIN: No, if they become chronically homeless, and you're mapping out what their life is like, their experiences — it could be anything from substance abuse, mental health, anything else — what's the number one correlated factor for predicting what chronically homeless individuals have in common?

SPENCER: I really don't know.

KEVIN: Youth homelessness. More than 50% of homeless adults — that's 50% of all homeless adults, chronic and not chronic — first experience homelessness as a teenager. And for chronically homeless it's even more; it's the number one predictor.

SPENCER: Are you saying that, for people who are chronically homeless, that they began to experience it in their youth and they just continued being homeless? Or do you mean, they more likely got housing at some point, but then lost it again?

KEVIN: The latter. Both happen, but the having experienced homelessness at some point in their youth, they're much more susceptible to falling back into homelessness, and then being chronically homeless. And again, if we look at what would cause a young person to end up experiencing homelessness at any point in their life, as a young person? That's where we get into, what's the economic resources that may be available to that family? What support do they have? It's coming from poverty, coming from a very low socioeconomic status. Or as the case for LGBTQ youth, coming from perhaps an unsafe home environment, it just skyrockets the likelihood of experiencing chronic homelessness as an adult.

SPENCER: So it seems like a chunk of what's happening is these folks, they are living in poverty when they're young. They also have maybe fewer strong ties that can help them through difficult situations. They end up experiencing homelessness at some point when they're young. Usually they'll get housing again, but then they will end up finding themselves homeless again as an adult. What are some of the other factors that you think are going on that are driving these situations?

KEVIN: I think one of the main drivers for homelessness is also foster care. For children who age out of foster care, 36% of those young people will experience homelessness by the time they're 26 years old. And for Black young people who age out of foster care, that number goes up to 60%, will experience homelessness by the time they're 26 years old. 60%. So it's horrifying. And looking at homelessness as one of the most, if not the most, intersectional issue of our time — mental health, behavioral health, we talked about criminal justice system, involvement at a young age in the criminal justice system, foster care, youth development, health care, housing, socioeconomic status — at some level, all broken systems, all roads that are tenuous to travel on in our country lead to homelessness. I think it's important to look at all those systems as part of what the experience of individuals who are chronically homeless either are currently going through or have been through, to get to a better sense of where we may need to go to resolve this issue.

SPENCER: We talked about the role of substance abuse addiction in the broader population of people suffering from homelessness, but what about in this chronic homeless population? And obviously, substance abuse can be both a cause and something that happens later, right? Can you talk about that a moment in this particular population? But also to what extent is it a cause versus just an effect of homelessness?

KEVIN: Yeah, I mean, certainly both. If we look at first the causal aspects, probably many of your listeners know, and folks who are passionate about this issue, we have had a deinstitutionalization where we wanted to move away in the 80s, from this kind of "One Flew Over the Cuckoo's Nest" level of care of institutionalizing people with severe mental health issues, severe substance abuse issues. And the plan at the time was to have a nationwide network of well-funded local community recovery centers and treatment programs. Well, unfortunately, as we know, that did not happen, that was not funded. And so we had deinstitutionalization and basically have left folks who would otherwise be getting care at a local level or in a major institutional setting, to the streets and to county jails. The county jail in most counties is the institution that has the most number of mental health patients in the country. And the criminal justice system, if we look at prisons and jails, I think it's something like 65 to 70% of people who are in prison have some kind of substance abuse addiction, some kind of substance issue. And so it's less of a deinstitutionalization that happened and more of a trans-institutionalization where they left one system for another, which is the criminal justice system, hospitals, emergency rooms, and the streets. Thinking about the tie-in of the criminal justice system of mental health, the lack of recovery centers is a big part of it. An example story, someone like Timothy, Timothy was a person that had a long sentence in prison. He was removed from his family. He spent years behind bars. When he was discharged, he tried his best to stay away from substances. And in his case, he was successful. He was able to prevent that. But having a felony on his record, he was essentially sentenced to a lifetime of second class citizenry, where he was no longer eligible for housing, no longer eligible for public benefits, no longer eligible for housing choice vouchers in public housing, no longer able to have the same work opportunities. And so he lived and eventually died on the streets. And though in his case, he was one of the individuals who did not have a substance abuse issue coming out of a prison situation, he was essentially confined to a lifetime of second class citizenry living on the streets. And I think when we look system by system at what happens when folks don't get the care they need, homelessness becomes almost an inevitable result of these broken systems.

SPENCER: If it's okay with you, I'd like to describe some examples of different people we could find experiencing chronic homelessness and ask, for each one, what do you think the ideal system would look like to help them? Case study one: imagine we have a person, they have severe schizophrenia, they've been living on the streets for a long time. In a really good system that's designed to do a really good job of people helping people like this, what would happen?

KEVIN: Well, ideally, they'd be able to access treatment and the hospital medication that they need to get stabilized, to be able to have some kind of decent quality of life for themselves. And then, once they do, they'd have housing assistance and other forms of support. Not as a prerequisite but as part of their recovery journey is being able to be housed. I have loved ones in my own life who still struggle with schizophrenia, and the quality of life that they're able to have is in large part because they're getting the treatment that they need. So having some kind of treatment that allows someone who's living with schizophrenia to have a level of stability, and being able to be part of society and not be in an untreated state is essential. But I just surface one voice of a person who has lived with schizophrenia. There's a man named Joseph whom I cite in the book, whom I met, and he reminded me of my uncle quite a bit. He said he was living with schizophrenia, experiencing homelessness. And I asked him, "What do you wish people knew about you, Joseph, that maybe they don't? What's it like to be you? Is there anything you wish that the rest of us knew?" He said, "Well, the only thing I wish people knew, is that I'm so much more of a threat to myself than I would ever be to them." And I think it's important when we're talking about groups — especially groups that we're not part of — not to let stand the assumptions that we may quickly make, which is, "Oh, my gosh, someone who's untreated, struggling with schizophrenia, they're likely to commit some kind of heinous crime or endanger the general public." That's just, by and large, not true. It tends to be that those individuals like Joseph could be, again, more of a threat to themselves. But when we actually look at crime statistics involving people who are unsheltered chronically homeless, whether they have an untreated mental health issue or not, most often the perpetrator is a housed person, rather than an unhoused person.

SPENCER: That's a good clarification. And what you described in terms of how to help this person makes perfect sense. Well, what else are you going to do other than give them the treatment they need? There are treatments for schizophrenia. But I think where it gets really complicated is, who is actually going to give them the treatment? And what if the person is not interested in the treatment, or they can't even understand that they need treatment, or they're afraid of the person who's offering treatment, as people with schizophrenia often have fear and paranoia? How do you think that should be handled in an ideal system?

KEVIN: Yeah, with a lot of care, a lot of gentleness ideally. With my uncle, whether he'd be open to treatment or not really depended on the day. Some days were good days where he would be willing to take his meds and get the help that he needed and work with us as his family and medical providers. And other days were not good days. And I've learned with a lot of this work that the starting point should be that, whether it's a good day or a bad day for someone like my uncle, who may be living with schizophrenia and untreated on the streets, that they'd know that the doors are open, and that there's help available to them if they choose to walk through those doors.

SPENCER: Is that not true right now in cities like New York and San Francisco?

KEVIN:

No, it's not. If you want treatment, if you want support, your best bet is, in many cities, people go into the hospital, go into the emergency department and are asking for help. Even if they're able to stabilize and have some medications and some support for a few days, they're discharged back to homelessness. There's no long-term recovery, no long-term support. The administrative burden of being unsheltered to begin with, is just shocking. When I started this journey, I was interested to see what it was like, for a 24-hour period, to be unsheltered. Together with a couple volunteers, who basically said, "Yeah, I'm willing to do this 24-hour experience," I said, "Okay, you're going to be on the streets for 24 hours. Your goal is to get food, get shelter, get hygiene, some kind of sanitation, a shower, and then (I think it was) getting money." Those were the goals that they had. So we spent 24 hours on the streets with them just observing and seeing what they do to meet these basic needs. And 24 hours went by, and they were able to meet (I think) three of the four goals that we had set forth. They found a shelter that they could stay at, they found food, and they got some money on the streets. I don't know if they got the shower in time. But the thing that was eye opening in that, Spencer, was, it took 20 of the 24 hours to get those basic needs met, walking from one place to another, waiting in line, being told that this is closed and you go across town, trying to get bus fare, getting out, waiting for the bus, getting on a bus or walking, being exhausted, carrying your bags, carrying your stuff. And again, we're in a relatively exceptionally privileged spot because we've basically flown into the streets just for this experiment. And so we still have our devices, we still have good health, we have clean clothes on, we feel okay about our appearance, showered the night before. And it took the entire day just to get your basic needs met, not to get ahead, not to start making sure you get the right meds at this time, or this treatment or job application or your ID card or reconnect to a loved one that you've disconnected from. And so I think that just the sheer exhaustion of what it takes to survive on the streets day in and day out...and we're talking not days or months. There's people that we've served as an organization at Miracle Messages, where they've recorded a message and we've reunited them with their loved ones. We had one guy who was disconnected for 67 years from his loved ones, and had been experiencing homelessness on and off for 67 years. Twenty years, 30 years. 40 years is not atypical. So I just wanted to share that, even if the person is open to this conversation, around mental health issues and schizophrenia particularly, the time, the burden, the level of administration that's required to try to navigate all this, and the emotional aspects, feeling perhaps like do they deserve the kind of support that may be available to them. And this is assuming that's available, and in most communities, it's not. It's a very fragmented siloed system. There's very little coordination between organizations. There's very little warm hand-off. California passed Senate Bill 1152 a few years ago, the dignity and discharge law, which basically mandates that hospitals have to discharge people to housing or some kind of stable situation or family or a shelter, rather than the streets. And it's a joke because it's unenforced, it's unenforceable. It's a mandate without resources. So I think it's important in these conversations to get as close as we can to what the lived experience is like, for people trying to get stable, trying to get the kind of support that perhaps someone who's living with schizophrenia who is housed and has the support of family, may be able to access much more easily.

SPENCER: Something that I feel like we've been circling around but haven't gotten to the heart of here is, suppose you have someone who's severely schizophrenic, they're living on the street, they're not willing to undergo treatment, or maybe they're don't understand that they're being offered treatment, or they're afraid of the people offering them treatment and so on. What should a society do in such a situation?

KEVIN: It's such an important question and actually, there's a section of my book that really just speaks directly to this. Do you mind if I do the Reading Rainbow thing once again?

SPENCER: Please go ahead.

KEVIN: Okay, thanks, Spencer. This is under the "Solutions: fixing broken systems." The book is basically "Humanity" section, where humanity falls short on this issue, the "Systems" section, what systems are broken, like housing and the criminal justice system, things we talked about, and then what are the solutions, both in terms of humanity and systems. This is in the mental health section of solutions. "It is also imperative that we find a happy medium between the unforgiving state mental institutions of the past and today's unacceptable status quo, where people with untreated severe mental illnesses are left to live and die in broken-down tents and tarps on city streets, endangering themselves and others. Partnering law enforcement with social workers and mental health workers seems like a reasonable step in the right direction, as does developing independent community-based outreach programs. Outreach must be coupled with more hospital beds, recovery and treatment program spots, and compassionate — albeit controversial — interventions like involuntary temporary psychiatric holds, and even involuntary treatment for individuals experiencing severe mental health crises who pose a severe threat to themselves or others, and are unable to care for themselves to a degree that risks serious self-harm." And increasingly (and this is just me paraphrasing now), physicians and folks in the medical space are calling for some embrace of involuntary treatment in the form of therapy, social workers, housing referrals, medication, other interventions, in hospital or on an outpatient basis. But the rub on this one really becomes great. You bring someone in, give them treatment that perhaps they're not voluntarily accepting because there's a risk that the person is a harm to themselves or others. So under some very limited criteria, that happens, well, then what? It's not a permanent state that you can have them in. What are the investments of psychiatric beds that are needed, funding for outreach teams, mobile crisis care, a coordinated plan, beyond the initial commitment that includes housing? I think there is a role for involuntary treatments, but, because of the loss of autonomy and agency, the violation of human rights that is a trade-off, it has to be coupled with the kinds of support that all of us need, and folks who are coming out of such a situation would especially need to regain some kind of stability and have a quality of life. And right now, that's not the case. So the two go together. It's a 'yes, and' kind of thing.

SPENCER: I understand that that view is not necessarily accepted among all people who are trying to help the situation. Some people think involuntary treatment should essentially never be done. I'm curious: what do you think the crux of that disagreement is that you have with them? Do you think it's more an issue of values, where you say, "Well, look, autonomy is really important, but it's not the only thing that's important. These people, maybe their lives could be vastly improved if we temporarily violate their autonomy." So it's just this value trade-off and maybe you place different weights on the different values? Or do you think there's something more fundamental that you disagree with them about?

KEVIN: I definitely am not in the majority right now, unfortunately, on this issue. I think most people in the homeless services space, they're wanting to protect autonomy where it's perhaps advantageous or convenient to do so. And that's okay, let's give this person the services that we're continuing to offer on this ongoing basis, but perhaps not in a way that would be, "Let's give them money directly," through things like basic income, where we've seen tremendous results. So I am in the minority on this basis. And the reason I believe what I do is, first, I think there are trade-offs in society, and I don't think the quality of life of someone like my Uncle Mark, who would be on the streets with untreated schizophrenia, that's no quality of life for him and for the people who love him. Families like mine, in my uncle's case, or as we hear from family members in our reunification work, they're usually the ones who are the most in favor of limited but intentional involuntary treatment and voluntary support, if a person is a risk to themselves or to others. That feels like a common sense thing that also (I think) aligns with loving the person who is in that situation and wanting to see them have a decent quality of life. I think we have swung the pendulum way to the other side, from institutionalization. We don't want to go back to "One Flew Over the Cuckoo's Nest." We don't want to go back to people being squirreled away for months or years in horrible mental health hospitals. But there's got to be an alternative to basically letting people live and die with very little quality of life, as a threat to themselves or to others on the streets, or in county jails or in emergency departments. It's not sustainable. It's not a long-term path. And I think, in the future, we'll look back with shock that there wasn't more done in our society to get people the treatment that they need.

SPENCER: What would their counter argument be to that, though? What would they say in terms of arguing that, no, if someone doesn't want to get treatment, even if they're severely schizophrenic and suffering tremendously, and confused about what's happening and have difficulty caring for themselves, they should not be forced into treatment?

KEVIN: I think the argument would really be twofold. It's, one, around autonomy, putting perhaps autonomy and agency of the individual above all else. And again, I would say that perhaps that doesn't apply in all settings, all programs, but I think it would be an autonomy question. And then I think the other one would be around distrust in the service sector, distrust in the institutions, that they're going to get this right. If you say you're going to have some kind of limit... And we already, by the way, have involuntary holds on a limited basis. A 5150 means that someone's going to have a 48- or 72-hour hold, somewhere in there, against their will. They're going to be detained for a limited amount of time. It's not a long time. It's a relatively short amount of time. But we already do have a form of that. And so I think in a free society, there are trade-offs that we have to make between freedom and live and let live and letting people be in whatever condition they're in and just turning a blind eye to having some kind of quality of life for folks. But I'm giving you my side of it. I think the counter argument is, again, around autonomy and around, well, if you are doing treatment, what's to ensure that they're looked after: their human rights, that they're getting the support they need, that it's not above and beyond. Because we've often conflated social work and outreach with the role that police officers have to play in our society. We've made homelessness into a criminalized state where it's illegal to be homeless in many jurisdictions and 911 calls have skyrocketed up for reporting people experiencing homelessness. And so if we are essentially looking at homelessness as a question around a police matter rather than as a community matter, that's terrifying to think of treating homelessness as a police matter, and then having some kind of involuntary hold on a more permanent basis or less oversight, that's terrifying. I wouldn't be in favor of that either. But once you start talking, well, we'd need outreach workers, caseworkers, psychiatrists, loved ones, to be part of the process. And doing so in a limited way that involves a wider assortment of community members, and you don't put the burden on law enforcement — who have an incredibly hard job in the country — serving as essentially armed social workers, then you can actually have, I think, a space for involuntary treatment, that's actually more humane than leaving someone to die on the streets in their condition.

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SPENCER: You said something earlier that surprised me a lot, which is that, if someone with severe schizophrenia wanted to get long-term treatment, that it might be difficult for them to get it in a place like New York or San Francisco. They could go to the emergency room and get temporary treatment but then, in a few days, they'd be out of there. And the reason that surprised me is because it just seems like there's so many nonprofits offering services, and that seems like such a basic obvious service to offer, that someone who's ready to get treatment for a severe mental health challenge, I would think there would be multiple nonprofits ready, lined up to give it to them. Is that really not the case?

KEVIN: When it goes to the numbers again that we talked about, when we're zeroing in on chronic homeless individuals, outsize the number of people who have some kind of substance abuse issue, mental health issue within that population. Not everyone who's experiencing homelessness, but within this population, we're focusing on the demand for these services, the need for these services far outpaces the supply that's available. And even if there's (say) enough hospital beds, which there are not... We've seen this with the pandemic; the system of care that we have in our country does not operate based on times of crisis, which we're now in with our unhoused neighbors. It's kind of, "Let's have the minimum and we'll have long waiting lists, a waiting room." People can spend hours or days even, waiting for treatment. If you have a psychiatric issue, the problem is, if you're waiting beyond just this window of opportunity, you very quickly lose that window. And then you end up having more of a reliance on things like involuntary treatments or even involving law enforcement because at the moment in time in which a person like Jeffrey — that's a story that I shared earlier in the podcast — he was open, at that moment of family reunification, to treatment. He had schizophrenia. He had a substance abuse issue. He was addicted to alcohol, had alcoholism. He lived with that disease on the streets of addiction. And at this exact moment, where his family was flying across the country — actually Jennifer was afraid of airplanes so she took a train — so training across the country, four days from Pennsylvania, had a whole community of people saying, "We want him back here. We miss him. He's a beloved member of our community. Here's his high school yearbook photo." "I work at the congressman's office. Does he need a job?" "I work in construction. Does he need work? Does he need health care?" Raising $5,000, to bring him home on an online fundraising campaign, literally $5,000 to bring a chronically homeless individual — and I'm using the terms intentionally to be a little bit stereotypical — like here's this person that no one wants, the biggest problem. Whole community is ready to bring him home, help him out, and at that moment, he's open to needing treatment, we couldn't find any referral organizations that would be willing to get him the help that he needed. We tried to contact different medical providers. It's complicated. There's waitlists. It's convoluted. I'm not trying to totally cast shade at all organizations doing incredible work. But there's waitlists, there's processes, there's a bureaucratic process to get someone like Jeffrey into treatment, and we lost our opportunity, we missed the window, because at that point, very quickly after, he said, "Ah, this is too much trouble. Forget it, I'm not willing to meet these preconditions to go home." If you want to go home, we have to have you stabilized. And in order to stabilize, we have to get you treatment. And that window was... We weren't able to get him the support he needed from other providers, and he ended up living the next few years on the streets and ended up passing away on the streets. It's a sad ending to that story.

SPENCER: What confused me so much about what you just said is these statistics that I see that say that, in New York and San Francisco, the city spent something like $57,000 a year on people, per person experiencing homelessness. Now, are those statistics bullshit? If they're not bullshit, what on earth is going on? How could it both be that $57,000 per year spent per person, and also people can't get basic treatment that they absolutely need?

KEVIN: Yeah. I'm trying to think of an analogy for this. Our homeless service system today is designed to respond to the most emergent needs, not looking at the long-term outcomes at all of what someone may need to get off the streets. So the money, the 57,000 — I've seen upwards of 80,000, 100,000 — anything when we're talking five-digit figures to maintain someone on the streets for a year: police, fire, emergency services, sanitation, shelter — a shelter system is incredibly costly — all these collectively, basically responding to crisis. You can't walk down the street for a long period of time in a major city like San Francisco or New York, and not see a firetruck zooming down the road or an ambulance going to and then picking up someone who might be experiencing homelessness and bringing them to an emergency room. And you go into an emergency room in the US. For people experiencing homelessness who go and receive emergency services, 50% of the visits by people experiencing homelessness are from 10% of the people who are experiencing homelessness. It's high utilizers, to put it in a term —it's not ideal, it's a little derisive — but 'frequent fliers of the emergency room.' And so we have this apparatus that is constantly in crisis response mode without saying, "Let's actually spend this money on developing long-term housing options, long-term treatment options, programs like basic income where, when we did our basic income pilot, we gave $500 a month for six months to about 14 individuals experiencing homelessness, all of whom were in our phone buddy program. Within six months, two thirds of those individuals were able to get a house, were able to secure stable housing. They used the money better than we could have used it for them. Now many of those individuals were not necessarily in the demographic of people experiencing homelessness, chronic, individual, years or decades on the streets, but some of them were. But I think instead of looking at what we know works, and the programs and support and the basic needs that we all need to be met, we've essentially responded to it as an emergency matter in crisis response mode, and that leads to high costs and very poor long-term outcomes. And the last thing, just to mention, Spencer, that I think is important to talk about, and again, we're broadening the conversation on homelessness is, it's not just what's happening on the streets. Homeless services itself, though there's a lot of criticism that's well-merited, homeless services don't cause homelessness. And in San Francisco right now, for every one person in San Francisco who is securely housed with family reunification and permanent supportive housing, in some kind of tiny home village of sorts, there's three people who will end up experiencing homelessness. So it's as much an inflow issue, where the systems are just buckling under the demand, the need, and are totally overwhelmed, and ill-equipped to handle it.

SPENCER: It really boggles the mind how poorly that money seems to be being allocated. Based on what you're saying, basically, instead of giving people the things that are known to work there, the money is kind of being wasted on just really short-term fixes that aren't solving the underlying problem. But with regard to that, you're referring to what's known to work. Well, what is known to work? What actually is effective from your point of view?

KEVIN: We can't be against what we see as conditions on the streets and the situation of chronic homelessness. We can't be against that and also against building more affordable housing in our communities, in our neighborhoods. You can pick one; you can't go with both. Unfortunately, there's tremendous pushback that happens anytime any kind of new affordable housing — whether it's a duplex, triplex, tiny home village, permanent supportive housing units, public housing — all that is just anathema to many communities, and there's protests and there's pushback. And so it's so difficult to, not only find places to build the housing, but then the cost of the housing and where the money's allocated. You end up having a situation where we're not investing. We have a nationwide shortage of over seven million affordable housing units to meet current demand. So I think we could build more housing. It's the one major thing. We haven't talked too much today about how many people experiencing homelessness do have jobs and are working part-time or full-time. About half of people who are in shelters have a job of some sort. But those individuals, people like Gabe and Laney, whom I feature in the book, have worked full-time at minimum wage. Of the 3000-plus counties in the United States, there's not a single county where working full-time at a minimum wage job is enough to afford the median price for a two-bedroom apartment. And there's only less than 1% of counties where the median price of a one-bedroom apartment you can afford if you're working full-time at a minimum wage job. So we need to look both at affordable and accessible housing, and we also need to look at what the National Low Income Housing Coalition has called for, of a housing wage. How much do people need to be paid? And what benefit programs need to be coupled with that payment to ensure that someone who's working full-time can afford housing? So those are a couple examples of solutions. I think the foster care issue, we talked about a little bit, and one individual who's featured in the book, who was in the foster care system and experienced homelessness. Many who are in the foster care system, one in three will age out. And one in three who age out will experience homelessness by the time they're 26 and 60%, for Black young people. Raising the foster care age limit from 18 to 21, 24, that's something that could also help to give more time to try to find a longer-term plan, stability, support them, higher education, trade schools. So that's something that I think needs to be done. I was initially a skeptic around basic income. I was not sure if this would do more harm than good. I didn't know what the outcomes would be. I couldn't imagine that a relatively small amount of money could lead to someone getting housed, let alone, having more stability in terms of food security, dealing with family emergencies, child care, paying down debt, storage. But there's now enough evidence around basic income that has convinced me through our own pilot and others, that basic income for some individuals experiencing homelessness is one of the most cost-effective, humane and scalable approaches we have. But if homelessness is one of the most intersectional issues of our time, and it also involves breakdowns not only in these systems, but also in our humanity, it's going to require solutions on each of these systems, as well as in how we treat people in order for us to really get ahead and solve this issue.

SPENCER: Kevin, before we wrap up, how would you feel about doing a lightning round where I ask you really difficult questions, and you're forced to give short answers.

KEVIN: I'm gonna do my best. But I don't think I've done a great job today on that test. [laughs] So give me a little bit of grace if I run a little long.

SPENCER: Of course. Okay, first question, lightning round: why give socks rather than money? If you give money, they can spend it on anything they want. Presumably, they can make it fit their needs better. You also mentioned that mainly people will spend the money on food anyway, which just seems like a fine thing to spend it on.

KEVIN: The reason I give socks rather than money is, I think there's something valuable to just having a conversation. It's never that I just give socks and then walk away. It's giving socks and then using that as a starting point to have an interaction. And my hope is that, more than a couple dollars which I could give — and I was being a little bit dramatic, I sometimes will give a few bucks — but more of the time than not, I find that inviting someone to have a conversation, getting to know their situation, trying to work to maybe identify opportunities, things that they're facing that are challenges of why they're experiencing homelessness, is a lot more beneficial in the long run. And also, selfishly, it allows me a chance to get to know another person experiencing homelessness to understand what the situation is like, to see what barriers exist. So I use socks as an excuse and as a means to start a conversation rather than as just an item in and of itself to pass out.

SPENCER: If people have (let's say) $20 a month they want to give to help this cause, they could give it directly to people experiencing homelessness, they could give it to nonprofits out there. Where would you advise them to give this money to make it go as far as possible?

KEVIN: $20 a month isn't much. I don't know how far that would go.

SPENCER: Sure, but they want to chip in and they want to help a little bit.

KEVIN: They want to chip in. I think supporting basic income pilots is a great way to go.

SPENCER: Is food much of an issue for people experiencing homelessness? Because on the one hand, you might say, if you don't have a significant source of income, obviously, worrying about eating is a really big deal. On the other hand, at least in New York, you just see restaurants throwing out just massive amounts of food all the time. And there seem to be a lot of nonprofits that are helping collect this food. So how big of an issue is it really, for people to get food?

KEVIN: It's a pretty substantial issue. I think it's not to the level where people are going to starve to death on the streets, overall. But I think food security is a major issue in our country in general. There's many young people who go to school and rely on subsidized or free lunches because they don't have enough food at home. And so there may be a plethora of food that we're producing as a nation, but it's a distribution question of, is it reaching the people who are hungry, who need it now. I think for people experiencing homelessness, especially those who have dietary restrictions, and I'm not just saying, oh, you're vegetarian or pescatarian. I'm saying you're diabetic, and some foods and some drinks, they're high sugar, they could kill you, or could cause serious issues. So high quality, nutritious food is a major need for people who are housed as well as unhoused in our country. And for folks who are experiencing homelessness, it's also the case.

SPENCER: There's been this case recently in Brooklyn, of a person in a certain neighborhood who either seems to be drug addicted or to have some severe mental health challenge. But the way it's manifesting is in aggression on the people in that neighborhood where they're doing things like running up to people and shoving them, or doing things that are scaring people, not that they have hurt someone really badly, such that the police come and arrest them. It hasn't gotten to that level. And so what's happening is that the neighbors in that area feel like they're being terrorized. But they also don't feel like they know what to do about it. What do you think the right solution is in a situation like that?

KEVIN: Ideally, we'd have a phone number where instead of calling the cops, we'd call a caseworker or social worker. If the person has gotten violent, they're assaulting someone else, unfortunately, there's not much in our country right now other than involving police. But there are programs in the Bay Area. We have a program called 211 where, if someone is having a psychiatric emergency, some kind of mental health crisis, acute on the streets, or posing a threat to themselves or others, you can call 211. And, ideally, there'll be a person who is going to respond to that and come and have the training and support that's needed. But I don't think it's something where we're doing anyone any good by allowing a situation like that to just persist without involving some kind of support agency. Ideally, it would be getting them the mental health support, the treatment that they need. But if they're assaulting people, then it could be a law enforcement matter as well.

SPENCER: One really striking difference that I observed just walking around New York versus walking around San Francisco, is that in New York, I pretty much never see someone doing drugs, except maybe smoking weed or whatever, but that's a special case, right? In San Francisco, even though I go there far less often — I don't live there — when I'm there, I see people doing drugs. It's just obvious that they're doing drugs. And it seems like this is a different attitude in policing. And I'm wondering what you think the most helpful attitude in policing is around drug use.

KEVIN: I think there's a difference between people who are selling drugs on the streets, and then people who have some kind of addiction issues. Folks who have addiction issues, they need as much compassion and support and access to treatment as we can offer. We've talked about quite a few ways to do that involving caseworkers, social workers, limited involuntary treatment, addiction, recovery programs, hospital beds, social support family, reintegration. There's a great TED talk that I think the quote was, "The opposite of addiction is not recovery; it's connection." It can be a very isolating 'otherizing' experience. And so at a moment where they need probably more love and support, it should not be something that we look at as incredibly stigmatized, 'otherized,' and 'what did they do?' It's a health issue, it's a disease. So that's for people who have substance abuse issues. People who are actually selling drugs, or bringing drugs to the streets, to me, that's a law enforcement matter.

SPENCER: What most surprised you when you investigated this issue? What was something that really subverted your expectations?

KEVIN: I didn't realize how relatable our unhoused neighbors would be. The first person I met to wear the GoPro camera, as I approached them, I found myself putting my hand in my pocket and grabbing my keys as a weapon, not knowing if they'd lunge at me, or not knowing... I honestly don't know what I was thinking. It was just this impulse. That was my starting point. And I'm not proud of it. It's not something that I'm like, "Yeah, let's boast about that." But I think that's actually probably where a lot of us are, and a lot of us feel. We don't know, we're afraid, we're wanting to do the right thing for ourselves, our families. But the closer I've got to our neighbors experiencing homelessness, the more I see myself in their stories or members of my family and friends. So I think taking the time to get to know our unhoused neighbors is something we haven't talked too much about in this conversation. But I think one of the fundamental issues around homelessness is, we don't know who they are. If I ask your listeners — and they can do this at home if they want, if they're still listening, — I'll ask them, "Raise your hand if you care about the issue of homelessness." Every hand shoots up. A second question, "Raise your hand if you know someone as a friend who's currently experiencing homelessness, a friend or family member," and when I give that talk and then maybe give a lecture and share that and ask that question, it's usually never more than about five to maybe ten percent of people who raise their hand on that second question. And in as non-judgmental a way as I know how to express, I say, "Well, that's part of the problem. We don't know who they are." We're talking about a group that's incredibly diverse, multifaceted, complicated, in the experience, the situation, the type of homelessness, as well as the causes, and we're talking about this group in the abstract. We have to get to know our unhoused neighbors as neighbors. And if we're ever going to do another podcast or conversation, I think, inviting a neighbor experiencing homelessness to join us as part of the conversation and share their experiences would have been great. But I think it's incumbent on each of us, if we care about this issue, to find a way to connect with an unhoused neighbor, as the son or daughter, brother or sister, neighbor, friend, person that they are. And my hope is that, by getting that close, what Bryan Stevenson — who's the founder of the Equal Justice Initiative, wrote "Just Mercy" — talks about of getting proximate. I actually think you start with proximity but you go even further. You have to get relational. And that, to me, is the critical missing piece in this entire conversation writ large, not today with Spencer, but just in general is, we don't know who they are. And so we're left asking questions of the internet, posting stuff on Twitter, asking someone who's never experienced homelessness a day in their life, to share the best that they can from ten years of experience and their family connection, and having an interested intellectual conversation, thoughtful, hopefully emotional. But it's never going to the level of relationship. And it would be such a missed opportunity if someone listens to this, and whether they agree with what we've talked about or things I've said, whether they think this is ridiculous, go find out for yourself.

SPENCER: One thing I observe in terms of the culture aspects of this, is that people on the Left seem to be much more likely to have extreme empathy for people experiencing homelessness, and not blame them at all for the situation; whereas, people on the Right seem like they're more likely to make it a matter of personal responsibility and say, "Well, what did you do that contributed to you being in this situation?" Not that they don't have empathy, but that they also are pushing this idea of personal responsibility, and, I think because of that, are less likely to have empathy than people on the Left. So I'm wondering, where do you see personal responsibility as coming into the conversation?

KEVIN: I disagree a bit with the premise of that question because I think there's two types of paternalism that we're really talking about. There's punitive paternalism, which is more of a law and order, the father figure (so to speak), the state as father figure as, "Well, you've done something wrong. You've misbehaved. You're a sinner. You're making bad choices, and you need to suffer the consequences." I think the progressive version of that — what I would call progressive paternalism — is looking at ourselves as almost like a savior complex. I think the historical parallel would be what Woodrow Wilson referred to, in speaking about Latin America, as "our little brown brothers down south," this self-righteousness that, "Well, we know what you need. We know better than you do," without actually spending time on the context, the story, the situation. And I think both types of paternalism are equally problematic. And to me, there may be, within a progressive paternalism, more of a description of ethics or empathy, I think, is what you're talking about. So within progressive paternalism, there may be more conversation around empathy and compassion. But does that translate to policies? Does that translate to housing development? Progressives are just as adamant about opposing affordable housing in their communities as any other group, if not more. NIMBYism and single family home zoning emerged out of Berkeley, California, which is not exactly a hotbed of conservatism. I think it's critical here to not see, frankly, any of us as taking the higher ground, looking really good here. I think all of us, whatever your politics, whatever your station is, we all play some kind of role in the situation that we're currently in. And I think, to me, the only way out of it is through getting up close and personal with people who are actually going through homelessness. But I do want to push back a little bit on that premise.

SPENCER: Do you disagree though, on the personal responsibility piece? This is just my observation. It seems like people on the Right are much more likely to say, "You, in this bad situation, are playing a role in creating this bad situation, need to take responsibility for that. Society doesn't need to solve your problem. You need to solve your problem." Is that not true?

KEVIN: I think that's a form of the punitive paternalism that I'm talking about. But I think there's a Left equivalent of saying, "Well, maybe you haven't made bad choices, but you need help. You can't make your own choices for yourself. I feel so sorry for you," without saying, "Well, what are the skills, the experiences, the talents that this person has that might be not being invested in, that aren't being supported, because our entire system of care is top-down, is presumptive of what the person needs and what will help them out. And so I think, yes, a more conservative lens on homelessness, would look at what issues, what challenges a person faces, what choices they've made, what's the responsibility in it. But if we actually think about, has any one of us made a lifetime filled with nothing but good decisions? Well, no, all of us have probably made mistakes. We're not angels but we're not devils either. We're human. We're complex. But most of us listening to this conversation are not experiencing homelessness. Is it that our choices and our decisions are that much relatively less bad than people experienced? Well, of course not. That's totally ridiculous. It's other things, independent of individual choices and responsibility happening, and that's looking at the systems that we're operating in, housing affordability, and wages, and the criminal justice system and all these other factors that we've talked about today. I think it's important to not create a false equivalence, that it's the exact same on conservative versus progressive stances on homelessness. But I think there's a level of paternalism and judgment that's pretty inherent to both stances that needs to be examined.

SPENCER: One thing that I've observed, and I think a lot of other people have observed, is that most chronically homeless people you see on the streets appear to be men. What are the stats on that and why would that be the case?

KEVIN: If we look at the causes of homelessness, for many individuals, it could be involvement in the criminal justice system. Men are much more likely than women to be involved in the criminal justice system. I think we look at some of the issues around substance abuse and mental health issues and seeking treatment, I think there's more of a stigma that maybe men have, under what it means to be a man in our society and masculinity, are less likely to seek treatment, or seek help, or ask for help, if needed, at a time that it may be available to them. And I think there's more resources available if a person is a woman or in a family unit experiencing homelessness; whereas, for individual adult men, there's not like shelters that tend to be catering to some of their needs. So you end up having a situation where your observation's right, that men account for somewhere between 70% to 80%, 85% of people experiencing homelessness. Again, I think it's attributed to some of these broken systems and how those broken systems may disproportionately hurt men. And I think you can have a similar conversation around some minority groups. In the US, Black people account for about 12% of the population overall, but about 37% of the homeless population, and that ratio is about three times larger presence among the homeless population than what you might anticipate from the overall population. That's almost identical to the outsized population of Black people in prison as well, most of whom are there because of some kind of drug-related offense. So these systems — and what I would consider some of the discriminatory aspects of some of these systems — disproportionately hurt some groups over others, and I think that can apply to gender as well as race.

SPENCER: Sometimes people will argue that people who are experiencing homelessness here, that San Francisco is a good place to be, because it has lots of services and so on. And that they will actually move there from a lot of other cities, or maybe even that other cities will encourage them to move there. How big of an issue is that?

KEVIN: It's a big issue in the sense that we think it's a big issue. We think that people move into a place because of the sunny weather or not, but when we actually look at the numbers, it couldn't be further from the truth. In the Bay Area... Well, I think in San Francisco, it's something like 70% of the people who are experiencing homelessness in San Francisco, are from San Francisco, or have lived there previously as a housed person. So our homeless neighbors were once our house neighbors. In California, it's something like 80% to 90% of the people who are experiencing homelessness in California, are from California. And I think that gets lost in the conversation a lot. We look at people as if they're transplants coming to a place to be homeless, to just get by, but it's really a homegrown issue. And I think in LA County, it's similar numbers; it's like 67% to 70%, 75%, have lived in LA County for a number of years previously as housed people. So this idea of 'not in my backyard,' well, our unhoused neighbors who were once our housed neighbors that, by and large, are already living in our backyard or in our neighborhoods. It's just now, they're experiencing homelessness.

SPENCER: Final question for you. This came from one of the listeners. Do people experiencing homelessness tend to connect a lot with each other, like do they have a lot of strong friendships among each other? Or do they generally feel very isolated socially, like they don't really have anyone to talk to?

KEVIN: Yeah, that's a great question. It depends on the person. You see tent encampments for a reason. There's a reason why people will set their tent in an area and have others that they trust in that area, because it's incredibly dangerous to be experiencing homelessness. The rates of sexual assaults of women is well over 90%, 95% of women who are experiencing homelessness will be sexually assaulted. For LGBTQ youth, incredible risk to sexual assault, sex trafficking, violence. So as much as a person who's experiencing homelessness can find other people who may not have economic resources to offer, but at least provide some kind of peer support or solidarity, it's incredibly important. And to the point that when people experiencing homelessness, when individuals are housed and offered housing, and we see individuals perhaps leave that housing and end up back on the streets, one of the biggest drivers of that is that the friends, the community, the relationships they had, those individuals have not been similarly housed. And so, they're now in a housing unit, four walls and a roof, but four walls and a roof don't make a house a home. It's relationships, it's community, and that person doesn't suddenly now have a stable life for the rest of their life. They're dealing with the same kinds of issues that all of us face at some point: health issues, job loss, psychological, emotional issues, feelings of isolation, fear. We rely on each other for that and that person does as well. So relationships among people experiencing homelessness and between people experiencing homelessness is incredibly valuable. The challenge, of course, is that, if folks are in a similarly awful, depressed, low-resource environment, there's not really much beyond the psychological emotional support that can be offered, or resource navigation, maybe helping to talk through complex systems that's needed. And then that's where relationships with people, like maybe many of the listeners who, if you're housed and you have a decent level of stability, a relationship with someone who's in a more stable situation can be life-changing. And we've seen recent research from Raj Chetty and his team at Harvard Opportunity Insights, where he found that, even more than zip code in predicting long-term life outcomes, education, income, different measures of successful life outcomes, a measure and a predictor of future success is the strength of your weak ties and whether you have a diffuse number of friends of different walks of life, different backgrounds through this massive analysis of Facebook connections that he did a few years ago. And so, if relationships are that important and critical to us, then it's absolutely vital to our unhoused neighbors. Peer support is part of it, but having relationships with people who are not unhoused for their sake, as well as for ours, is even more important.

SPENCER: Kevin, thanks so much for coming on.

KEVIN: Yeah, Spencer. Thanks for having me.

JOSH: Kevin's nonprofit, Miracle Messages, has a phone buddy program which matches volunteers from around the world with unhoused individuals for short weekly phone calls and texts one-to-one. They currently have a waitlist of a few dozen unhoused individuals waiting for a friend to talk to, and need more volunteers (who they train and support). Interested listeners can sign up at miraclemessages.org/getinvolved.

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