The Homeless

Sacramento County spends millions to aid homeless. Why is mental illness still so pervasive?

“You watch ‘Dirty Dancing’?”

For nearly two decades, Gloria Pizaña – a self-described “hot grandma” with a gap-toothed smile, swept-back hair and dark, laughing eyes – has struggled with housing insecurity and mental illness.

Perched on her walker at Friendship Park, a private site where the homeless charity Loaves & Fishes offers services, she is impeccably dressed. She wears a white button-down shirt knotted at her waist and cuffed denim shorts.

“It’s my ‘Baby’ look,” she said.

A vortex of factors – childhood sexual abuse, two abusive relationships over the course of nearly three decades, resentment and rejection from her three children, an addiction to methamphetamine and the absence of a stable home – has taken a toll on Pizaña’s mental health.

Five days into the new year of 2018, she swallowed a handful of pills. She woke up the next day at Sutter Medical Center.

“The deck of cards just came falling down,” Pizaña said.

Pizaña is one of about 5,570 homeless people in Sacramento County. Mental illness is a severe problem among Sacramento’s homeless, according to a federally mandated census conducted in January.

Gloria Pizaña walks near Friendship Park, a local hangout for homeless people, on Thursday, August 1, 2019, in Sacramento. Pizaña lives in Sister Nora’s Place, a long-term homeless shelter for women with a history of trauma, serious mental and physical illness. Arden Barnes

According to Sacramento Steps Forward, the nonprofit that conducts the point-in-time count every two years, 22 percent of homeless people report having a mental disability, and 21 percent have a psychiatric disability.

Experts overwhelmingly agree that homelessness and mental health issues can be intimately linked. According to an informal survey by Loaves & Fishes, the common denominator among homeless people is past experience with trauma – and homelessness is itself a traumatic experience.

“My belief is, if you didn’t have a mental illness before you became homeless, you’ll have one while you’re homeless,” said Kerrye Wheeler, director of Sister Nora’s Place, Loaves & Fishes’ program for mentally ill homeless women.

Among her program’s guests, she’s seen the whole spectrum of mental disorders, many stemming from past trauma: anxiety, depression, PTSD, bipolar disorder, schizophrenia.

Sacramento County now boasts what officials call a robust, welcoming network of programs for homeless individuals facing behavioral and mental health issues. Since 2017, the county has increased spending on mental and behavioral health services for homeless people: the 2017-18 budget was about $12 million, while the current 2019-20 budget is about $28.3 million.

Over the past three years, the county has spent more than $67 million toward the cause, over $20 million in excess of the $44 million it promised in 2017.

So why is the number of homeless people with mental health issues still disproportionately high?

Slipping through the cracks

“The system can be fairly complicated,” said Sheri Green, Sacramento County’s health program manager.

To break down the county’s mental health resources, Green highlights three “front doors.”

Any person, at any time, can walk into El Hogar Guest House, Wellness & Recovery Center North, and Wellness & Recovery Center South for help. These locations are situated at homelessness “hot spots,” according to Green, to allow for easy access.

At Wellness & Recovery Center, Medi-Cal recipients over the age of 18 encounter a safe place to play ping pong, enjoy air conditioning, and do some laundry. Most importantly, they have the chance to meet with psychiatrists and therapists, one-on-one. The WRC’s mental health program currently serves 570 clients.

These clients are sometimes referred to long-term mental health and housing programs, such as the Hope Cooperative.

Other long-term programs, which are in full partnership with Sacramento County and receive county funding, include El Hogar Sierra Elder Wellness, Turning Point, and Transcultural Wellness Center. A few operate outside the county system and exchange referrals with county-partnered programs, including Genesis at Loaves & Fishes.

The county also offers a homelessness hotline, at (916) 875-1055.

While more than 18 institutions in Sacramento are dedicated to aiding homeless people with mental health problems, people still slip through the cracks, for two main reasons.

The first is a severe shortage of psychiatrists, not just in Sacramento County, but across the nation. According to a 2017 report by the National Council Medical Director Institute, the pool of psychiatrists working within the public sector and insured populations declined by 10 percent from 2003 to 2013.

Hope Cooperative’s New Direction program, which provides therapy and psychiatry to homeless individuals, has struggled to find psychiatrists.

“Would you rather be a psychiatrist in your own office? Yeah,” said Karen Brockopp, director of programs and services. “We’ve lost psychiatrists to state Corrections because they get better benefits, a better salary, and they can sit at a computer and do telemedicine through the computer monitor.”

The psychiatrists and other members of staff hired by programs like WRC South are heavily overworked. Each WRC South staff member takes care of an average of 90 clients. WRC employs two psychiatrists in total – one full-time, who divides her week between two locations, and one part-time.

“You can never have enough staff,” said Heidi Cady, director at WRC South.

Second, homelessness itself is a barrier.

“They don’t have planners. They don’t have smart phones with agenda items in them. They don’t have those types of resources, and transportation,” Cady said.

At Hope Cooperative, psychiatrists report that 28 percent of homeless patients don’t show up to their appointments. At WRC South, it’s 40 percent. At Genesis, Loaves & Fishes’ mental health program, it’s roughly 50 percent.

Severe mental illness can also restrict a person’s ability to get help. “The hardest thing is when someone is so symptomatic they’re basically not able to consent to their own well-being,” said Vince Gallo, program director of Genesis. Even common disorders like depression can impair one’s ability to seek care, let alone those that distort reality, like schizophrenia.

Nor does attending an appointment guarantee adequate care. Socioeconomic and cultural differences separate doctors from these patients, impeding the communication necessary for a patient-physician encounter, Loaves & Fishes staff said.

Some homeless individuals also suffer from poor self-esteem as a result of trauma and the hostility they constantly encounter. Much of Gallo’s work involves convincing his clients that they deserve care.

Pizaña appears to be a beacon of self-love, but her dignity was hard-won. Two abusive relationships — a marriage to a physically abusive man that lasted 12 years, and an emotionally abusive relationship of 15 years — badly eroded her sense of self and established a pattern of vulnerability to abuse.

“My husband — he was the first man that beat the hell out of me. Seriously picked me up by the hair and beat me up,” she said. “And then your other relationships end up being the same way.”

During her second relationship, she internalized her partner’s debasing words, coming to believe that she was “so ugly on the inside.”

“I don’t feel like I can find myself in a romantic relationship anymore,” she said.

Her sense of undeserving extended beyond romantic relationships: it was difficult for her to believe that she deserved adequate medical care until her unsuccessful suicide attempt, which led to an extended period in intensive care units and a revolution in her self-regard.

“God says, ‘No. I don’t make ugly. I’m not ready to take you up yet,’” she said. “God says that I’m beautiful.” She paused for a long time, as if summoning her next words with great effort. “I am.”

But Gallo has also witnessed people improve radically after taking antipsychotic medication, only to abruptly halt their course of treatment. Though this might appear self-sabotaging, Gallo pointed out that the side effects of medication – drowsiness, in some cases – can be dangerous on the streets. “Who wants to be off their guard out there?”

‘Growth makes up for the rules’

At Sister Nora’s Place on a recent Tuesday, the TV room was lit by the screen’s dull glow. The windows were set high on the wall, the blinds partially closed.

“We fight over the channels,” Pizaña said. “Like normal people.”

Pizaña, playing the host, introduced fellow residents of Sister Nora’s Place and gave a queenly tour of her cubbyhole within the upstairs dorm room. The tiny space is decked out in pink florals, cute messages – “LOVE,” “XOXO” – and a picture of Martin Luther King Jr.

Upstairs are 12 cubicles, where curtains drawn across slim entrances offer some privacy. Downstairs, four women sleep in a transitional room, intended to shelter them for a week or so before moving them upstairs. Due to a housing shortage, two of the women in the transitional room have lived there for a year and a half. Boxes of medication sit in a large beige cabinet in the staff office.

Sister Nora’s is licensed as an emergency overnight shelter, but in reality provides open-ended shelter for 16 women suffering from diagnosed mental illness and chronic homelessness.

The staff offer support that counteracts missed appointments and relapses – case management, accompaniment to appointments, group counseling – and, most importantly, a sense of stability.

“When that stability really reaches them, what often happens is a release of emotion,” Gallo said. “There’s this flood of whatever they’ve been suppressing in survival mode.”

Still, Sister Nora’s Place is a place of limbo for Pizaña.

“It’s not mine,” she said.

Rhythms of life revolve around a timetable: use the kitchen by 5:30 a.m., leave the facility by 8 a.m., be back by 3:30 p.m.

For the housed, safety and freedom aren’t mutually exclusive. But housing-insecure people must often pick between one of the other, or struggle to find either.

The safety is worth it, Pizaña said. She considers herself extremely lucky. Compared to other bargains homeless women make for imperfect forms of security, Sister Nora’s Place is a haven where the sense of safety is genuine and the women can grow.

Gloria Pizaña, 54, is pictured in her living space in Sister Nora’s Place, a long-term homeless shelter for women with a history of trauma, serious mental and physical illness, on Thursday, August 1, 2019, in Sacramento. Arden Barnes

The choice between “the lesser of two evils,” as Wheeler puts it, is one that unsheltered homeless women are often pressured to make. Being single renders them vulnerable to assault and theft, but the men they attach themselves to for protection are often abusive, violent, or unreliable.

“At least they’re a known abuser, not an unknown danger,” Gallo said, elaborating on the reasoning that drives this choice.

Sexual abuse and assault are far from exclusive to women, whether in childhood or adulthood. But the gendering of violence means women experience interpersonal violence more acutely.

Unsheltered women face disproportionately high rates of sexual assault and other forms of violence, including emotional abuse. According to a 2005 study by the University of Central Florida, 78.3 percent of homeless women interviewed had been subject to rape, physical assault and/or stalking at some point during their lives. Of the victimized women, 55.9 percent had been raped.

The same study found that 14.3 percent of homeless men had been raped – a similar rate to rape among women in general, according to the Rape, Abuse and Incest National Network, at 14.8 percent.

“Most of these women are very severely broken and vulnerable to predators,” Wheeler said. “That might be a heavy word, but they’re out there looking for vulnerable women.”

Women like Pizaña don’t have many options when it comes to immediate, emergency overnight women-only shelters in Sacramento.

Long-term shelters for women, such as St. John’s Shelter Program for Women and Children, have waiting lists of over 200, and intensive interview and application processes.

Sister Nora’s Place sets rigid time parameters for the sake of residents’ safety – with some leeway. The women can text ahead if they’ll be late. Three times a week they can get late-night passes to return by 10:30 p.m., and they have the option to stay out overnight twice a month. The latter is not a popular option.

“What they have to give up is trying to run the show,” Wheeler said. “Growth makes up for the rules.”

From abuse to independence

In 2015, Pizaña’s then-boyfriend sold their house in Del Paso Heights and drove her to Los Angeles without warning, where he deposited her on her son’s doorstep. On the drive down, he excoriated and degraded her: She was a worthless human being, undeserving of love, he told her.

She was in love with him – a man who was unfaithful and drove up their substance use. She weighed 80 pounds.

“My grandkids were asking me what kind of cancer I had,” she said. “And I didn’t know what to say, you know? ‘Your grandma’s a crackhead.’ ”

The following year, on returning to Sacramento to salvage her belongings, she received a call from her daughter Nicole. Don’t come back to L.A., she said. She’d given away Pizaña’s beloved dogs – a pair of Chihuahuas, Taco and Bella.

Pizaña moved in with a friend in Sacramento who gave her tough love and made her go cold turkey after 27 years of meth use.

Years of trauma had left their mark. She’d witnessed the murders and deaths of friends, not to mention the grievous injustices enacted on her own body and the disintegration of her family and relationships.

“I don’t grieve,” Pizaña said. “I don’t know how to grieve.”

She used relationships with men and substance abuse as dubious palliatives, but also turned to self-harm. “I’ve sliced myself, I’ve put flame to my skin,” she said.

After waking up in the intensive care unit at Sutter, she was shuttled in and out of hospital with mental health issues and pneumonia. Initially placed with Turning Point, Pizaña entered Sister Nora’s Place in May of last year, where she remains. At the time of her placement, she had received diagnoses of chronic depression, PTSD and suicidal tendencies.

She is in the process of registering for Social Security Disability Insurance. She qualifies for it because of a shattered kneecap from an accident two months ago – not because of her mental illnesses. Her psychiatrist considers her stable.

“I guess I must be doing really good,” she said, though she admits, at times, she doesn’t feel good.

“I’m on my own. I feel like an 18-year-old college student, on my own,” she said. Her eyes creased as she smiled. “I can’t rely on my daughter. No more man dependence.”

Though the care she receives isn’t perfect, Pizaña is firm in her sense of deserving and her desire for care – crucial aspects of the self-advocacy that the sometimes-unforgiving mental health system calls for.

“They call me ‘Glo,’ because I shine,” she said.

Gloria Pizaña, 54, is pictured outside Sister Nora’s Place, a long-term homeless shelter for women with a history of trauma, serious mental and physical illness, on Tuesday, July 30, 2019, in Sacramento. Arden Barnes
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Chalay Chalermkraivuth, from Yale University, is a local news reporter for The Sacramento Bee. She reports on arts and entertainment, the LGBTQ community and social justice. She grew up in Bangkok, Thailand.
Candice Wang, from Yale, is a local news reporter for The Sacramento Bee interested in climate change, sustainability, socioeconomic inequality, and culture. She grew up in Connecticut.