This story was originally published by CalMatters. Sign up for their newsletters.
Like many people who are or have been homeless, Jessica Scott struggles with debilitating anxiety.
When she finally moved from her stepfather’s car into a Sacramento apartment a few weeks ago, she said one thing played a major role in helping her take that step: Therapy.
“When you’re panicking so much that you can’t really talk to people, it’s difficult to do anything,” Scott said. That included making – and keeping – the numerous appointments required to find subsidized housing.
Scott used to have her therapy sessions with Anthony Villanueva, a clinician with One Community Health, on a park bench because she had nowhere else to go. But her most recent session in early July was on a blowup couch in her new living room. She credits her ability to get this housing — her first in two and a half years — partially to Villanueva teaching her breathing exercises to calm herself down.
Media stories, politicians and splashy state-funded mental health initiatives tend to focus on people who live on the street in the grip of psychosis or other severe mental illnesses — a highly visible but statistically uncommon problem. That overlooks a much quieter but more widespread issue: All across California, unhoused people are suffering at alarming rates from less obvious but potentially enervating mental health conditions, including anxiety, depression and post-traumatic stress disorder.
Some of those people manage to navigate the healthcare system, find a therapist and make regular trips to a clinic. Most do not. To fill that void, therapists are meeting their patients wherever they are, conducting therapy in a tent, a homeless shelter or a car on the side of the road.
That care is a major help to people like Scott. But there are far from enough street therapists to see everyone. Recent estimates put California’s homeless population at nearly 182,000, and a UCSF study of homeless Californians found that 48% of them reported symptoms of serious depression and 51% reported anxiety.
Doctors, nurses and clinicians who work with people on the street told CalMatters the numbers are even higher. They estimate between 80% and 90% of their patients have a mental health condition that could benefit from therapy – most commonly depression, anxiety and PTSD.
“I have no capacity to see the amount of patients that we have,” said social worker Lisette Carmona, who provides street therapy in Los Angeles with the USC street medicine team.
That’s despite the fact that street medicine, which brings basic medical care (sometimes including therapy) directly to homeless people in encampments and shelters, has rapidly expanded over the past few years. What started in the 1990s as a small, grassroots movement has ballooned into at least 70 teams in 34 counties in California, said USC Street Medicine Director Brett Feldman, who is considered one of the founding fathers of the field. In 2022, the state made it easier for those teams to bill Medi-Cal, helping them grow even more.
But they’re still vastly outnumbered, a problem with broad implications, because therapy isn’t just about making people on the street feel better. Practitioners say it also can be a crucial step to getting them into housing. The housing process is difficult and complicated, requiring people to go to the DMV to replace lost identification, answer a lengthy list of questions to determine their eligibility and apply for multiple waiting lists. It can take months or even years, often with plenty of setbacks along the way.
“It’s kind of a daunting process for anybody,” said Joann Bianchi Wojick, associate behavioral health director of LifeLong Medical Care’s Trust Health Center, which sends a street medicine team out to encampments in Oakland. “But when you’re feeling anxious or depressed, and you have more difficulty organizing your thoughts and your to-do list and your actions, it can feel so overwhelming.”
Once someone does get into housing, if they haven’t already learned to regulate their emotions in therapy, they risk lashing out at their landlord or new neighbors. That can be a quick ticket to getting evicted and landing back on the street.
That’s why street therapy is “so, so important,” said Dr. Katherine Koh, one of the country’s early pioneers of street psychiatry, who practices in Boston.
“It needs to be part of the treatment,” she said. “I really think just meds alone is rarely going to be the solution for anybody. It’s teaching people the skills that hopefully will continue to help maintain and regulate their behavior when they move into housing, because if they don’t have that, they’re just going to end up back on the street.”
Trauma on the streets leaves mental scars
While schizophrenia is what often comes to mind when people talk about mental health and homelessness, other ailments are far more common. The UCSF study of homeless Californians found that while two-thirds reported symptoms of mental health conditions, just 12% experienced hallucinations. Depression and anxiety were much more prevalent.
Some of that is caused or exacerbated by childhood trauma. A review by The Lancet Public Health journal of more than two dozen studies found that 90% of homeless adults had been through at least one adverse childhood experience, and more than half had been through four or more.
Living on the street is also terrible for people’s mental health. They suffer mental scars left by physical and sexual assaults experienced while homeless, psychological damage from having to maintain a constant state of hypervigilance and the mental anguish of feeling unwanted by society.
“It’s just causing a lot of suffering in our patients’ lives,” said Dr. Shane Collins, a psychiatrist on the USC street medicine team.
California’s “housing first” system prioritizes getting people into housing above all else, promising mental health care and other services will come once someone moves indoors. But housing is in short supply, and thousands of people are stuck waiting on the street without mental health care. Meanwhile, Gov. Gavin Newsom has put a significant focus recently on helping unhoused people with schizophrenia and other acute mental illnesses. He launched CARE Court, a court-based program that connects people in psychosis with treatment, and backed a 2024 statewide bond to fund mental health and substance use treatment beds.
In addition, some cities, including Los Angeles, have mobile outreach teams dedicated to helping people on the street with severe mental illnesses.
But for the thousands of unhoused people dealing with less-obvious mental health conditions, it’s easy to fall through the cracks.
Terri Roman, 57, has been homeless for 10 years. That’s plenty of time for the day-to-day brutality of life on the street — from drivers leaning on their horns at 4 a.m. just to be cruel and wake her up, to other unhoused people stealing her belongings — to take a toll on her mental health.
“The hard thing to cope with is the dislike of homeless people from everybody,” said Roman, who lives in an RV in Oakland with her partner and a dog named Bonehead. “It feels like nobody wants you anywhere.”
Like so many unhoused people, she’s also experienced bloodcurdling trauma while homeless. She witnessed a murder and then had to testify in court against the alleged killer — her own ex-boyfriend. Another time, she was grabbed, slapped and kicked by two masked men trying to steal her car at a gas station in the middle of the night.
“That’s really damaging,” she said. “Now I’m hyper-vigilant. I go off on people.” She glanced around as she spoke, constantly scanning her surroundings.
She could really use someone to talk to and help her process her trauma, Roman said.
When she asked her local street medicine team about counseling, they referred her to the Native American Health Center. She went for eight months. But it was hard to get there if she didn’t have money for gas. And she’d lose track of the appointments, with her phone constantly running out of battery and having nowhere to charge it. She missed three appointments, and said the center dropped her as a patient. Now she’s waiting to get back in.
It would help immensely if a therapist came to see people on the street instead, she said.
“Then homeless people would feel they had someone to turn to,” Roman said. “Or they would feel they’re not alone.”
Meeting people where they’re at
Some lucky street medicine teams have a psychiatrist, but psychiatrists willing to go to homeless encampments are scarce and their time is expensive. That means they often go out on the streets just one day a week, and tend to focus on diagnosing mental health conditions and prescribing medications. That leaves little time for therapy.
Collins, the psychiatrist on the USC street medicine team, estimates his team can provide therapy to only about 5% of the patients who could use it.
If street medicine teams do provide therapy, it’s usually done by social workers like Carmona, who works alongside Collins.
“I am doing therapy anywhere where my patient is at,” she said. “So you can find me on the riverbed, you can find me in a tent…Wherever the patient is comfortable, that’s where I’m conducting their therapy.”
Her sessions can last anywhere from 15 minutes to an hour and a half, depending on the patient. She sees some people once a week and others more sporadically. Because her patients can’t escape to a quiet room to be alone when they are upset, or zone out in front of the TV, Carmona thinks up alternative coping strategies for them, such as coloring and journaling. She also does short-notice calls for patients in crisis.
For Bert Andernié, 52, therapy helps him deal with the soul-crushing disappointments he experiences on the streets of San Francisco. For example, in May, his caseworker told him he’d gotten a housing placement. Later, he was told that actually, no, there wasn’t a spot for him. He still doesn’t know what happened.
“I was so pissed I was crying on the bus,” he said. “I was livid.”
Andernié doesn’t have many other people to talk to about his problems, so he hashed out his frustration with the therapist he got matched with after applying for the city’s General Assistance benefits.
“It’s nice to have somebody say, ‘yeah, you’re right, that is messed up,’” he said.
The debate over how to best use scarce therapy resources
Not everyone agrees that conducting therapy on the street is a good use of time. Some medical providers prefer to wait until someone is housed, or at least in a shelter.
Hollywood 2.0, a mental health team that prioritizes the sickest unhoused people in Los Angeles’ Hollywood neighborhood, doesn’t do traditional therapy on the street.
“It’s really hard to catch folks and catch them sober,” said psychiatrist Dr. Chance Cruz. “A lot of times I can’t even get a logical answer out of someone because they’re high. So that person couldn’t engage in therapy at that time.”
Dr. Chad Koyanagi, one of the national pioneers in street psychiatry who practices in Hawaii, prescribes medication but doesn’t do therapy on the street. “Probably their focus is going to be on finding their next meal, not their relationship with their parents,” he said. “That stuff is going to be dealt with at a later time when their basic needs are taken care of.”
Patients in therapy must feel safe before they can recover, and that’s often impossible when living on the street, said Rory Rieger, who oversees the Ritter Center’s behavioral health team in Marin County.
“There’s only so many things you can do when a person has that many vulnerabilities and is that stressed,” he said. “Therapy really doesn’t work for someone who is that stressed out.”
What his patients really need to make a dent in their mental health is housing.
Carmona “vehemently disagrees” with the idea that clinicians can’t do real therapy on the street, and says that idea caters to the comfort of the therapist, not the patient.
Carmona has seen patients who seemed hopeless when she met them quickly regain their optimism after starting therapy. The wins aren’t always monumental. Some weeks, it’s small victories, such as when a patient gets upset but refrains from self-harm.
Other teams use a both-and approach, such as LifeLong Medical Care in Alameda County. Initially, their street therapy is often crisis management — helping someone cope with losing their belongings in a sweep or get through their depression, said Bianchi Wojick, associate behavioral health director of the LifeLong Medical Care clinic. Once someone gets into a shelter or housing, they can more deeply explore their past trauma.
Even without an official therapist, regular medical check-ups on the street can look a lot like therapy. It’s not uncommon for patients to spill their hearts, or even cry, while an empathetic nurse is taking their blood pressure on the sidewalk.
For Valerie Campos, gamechanging mental health care didn’t come on the street — it came in a tiny home. She’d grown up homeless and then continued the pattern as an adult in Southern California, ending up getting trafficked and sexually abused. That trauma devastated her mental health. She developed PTSD, as well as depression and anxiety so severe that she couldn’t drive a car on the freeway.
“It was just terrible,” said Campos, 49. “It was hard to live minute by minute sometimes.”
During the COVID-19 pandemic, Campos moved into a tiny home transitional housing program in Redondo Beach. All of a sudden she had access to something that had seemed unreachable on the street: counseling.
Counselors came to Campos’ tiny home every two weeks and stayed as long as she needed. They didn’t judge her or her past, and so she began to open up, talking about her childhood, her homelessness, and everything she’d been through.
They taught her coping skills, the warning signs that could indicate her depression was rearing up again, and how to journal and keep track of her moods. They helped her get medication for depression and anxiety. She learned to recognize, and stop, her self-sabotaging behaviors.
“I’m a whole different person,” Campos said. “I’m back on the freeway, driving.”
Four years ago, Campos moved from the tiny home into her very own apartment in Gardena, thanks to a federal housing voucher. She isn’t sure how much longer she’ll be able to stay, as the program paying for her apartment — the federal Emergency Housing Vouchers — is running out of money, and Campos has been told her subsidy will end in December.
But she does know that getting mental health support saved her. Without it, she wouldn’t have been able to hold down an apartment. And without an apartment, she doesn’t think she would have made it.
“I don’t think I would be here right now,” she said, “if it wasn’t for the counseling and the housing.”
This story was reported with support from the Rosalynn Carter Fellowship for Mental Health Journalism.
