Why does society allow people who are obviously mentally ill to live on the streets? These people forage for food, lack adequate sanitation resources and sleep on sidewalks. They often talk to themselves and shout at voices that rack their brain. Most of them are dressed in layers of clothing that have not been washed and do not fit.
The mentally ill homeless are lumped in with other homeless, such as those who may be down on their luck and suffering financial hardship or those who are drug/alcohol users.
Los Angeles and California officials have become convinced that the best way to deal with all homeless individuals is to provide housing. Unfortunately, this approach fails to provide specific services for the mentally ill.
Is mental illness a social issue, a medical issue, or both?
Striving to inform residents about this difficult dilemma at its monthly meeting on January 27, the Pacific Palisades Task Force on Homeless tackled mental illness from the perspective of three experts: Dr. Joel Braslow, director of the Social Sciences Track of the UCLA-Caltech Medical Scientist Training Program; Dr. Enrico Castillo, a board-certified public psychiatrist and health services/health policy researcher with a dual appointment at the County Department of Mental Health and UCLA; and Dr. Roderick Shaner, former medical director of the County Department of Mental Health.
Why can’t doctors or social workers take the mentally ill off the streets and help them?
“Demedicalization — seeing mental illness as a social problem and fundamentally outside of medicine’s purview — has sent a lot of people back to the streets, and that’s not always in their best interest,” Braslow wrote in the The New England Journal of Medicine.
Currently, 5150 is the California law code allowing officials to hold someone who is mentally ill, provided they present a danger to him/herself and is gravely disabled. That person may be detained for up to 72 hours for assessment.
This definition of gravely disabled is interpreted differently. For example, as Breslow wrote in the NEJM: “Mr. N, a homeless man, was diagnosed with schizophrenia 30 years earlier. Psychotic, unable to house himself and hungry, Mr. N arrived at UCLA’s emergency room for care but was not admitted and was released.
“A resident recommended that he be admitted; the attending physician that he be discharged,” Dr. Braslow wrote, who added that once Mr. N was released, he ended up back on the streets and then in jail.
At the Task Force meeting, Breslow said: “If you are homeless and mentally ill, you are gravely disabled.”
PPTFH members expressed similar concerns. They had dealt with a Palisades homeless woman, who was also written about in the L.A. Times. The young woman was clearly psychotic. She lived on Pacific Palisades bluffs and wandered around town, sometimes talking to herself.
When task force members finally convinced officials to meet this woman in order to get her help, those officials didn’t want to hold her. The reasoning? She had just purchased a chicken from a local grocery store and was declared competent to take care of herself – she was considered not gravely disabled.
Local LAPD Officer John “Rusty” Redican said, “It frustrates me when I see someone who is gravely disabled and there’s nothing I can do. We have an obligation to those people on the street.”
Castillo recounted how a mentally ill person was in the emergency room and because he asked for a sandwich and was given one, that person was considered okay because he could provide for himself.
“There are increasing numbers of mentally ill brought into the UCLA emergency room by the police,” Braslow said, noting that about 5,000 mentally ill are housed in the Twin Towers correctional facility in downtown L.A. “While medical residents have wanted to admit them because of psychosis, they are incarcerated instead.”
Why don’t medical and governmental officials help the mentally ill?
“If we had all the resources, it would look differently,” Castillo said.
“It’s about resource allocation,” said Shaner, who pointed out that 5150 initially had good intentions, but over the last few years the mentally ill homeless have increased dramatically. “People [state officials] are worried about the economic impact. There’s limited money for health care for the mentally ill.”
Shaner explained that even though voters passed the Mental Health Service Act (Proposition 63) November 2004 and it has generated about $15 billion from those taxpayers who have personal income in excess of $1 million, the act has become saddled with so many restrictions that the money is devoted to outpatients, not for voluntary care.
“The passage of time since MHSA funding was approved has demonstrated that it has not been effectively directed to those inpatient services that would most benefit people gravely disabled by mental illness, especially those struggling in the streets,” Shaner wrote in a January 30 email to Circling the News.
“AB 1938 (Eggman) would clarify that the language of the Mental Health Services Act indeed permits the funding of inpatient mental health services, including services for people detained involuntarily due to Grave Disability under California Law,” Shaner said. “Improved funding for inpatient care is critically important to address the immediate needs of people most in need of mental health care.”
Braslow called the current situation for the mentally ill “immoral” and an increasingly untenable position.
“Asylums were created in the 1810s-1820s because insanity was seen as a medical problem,” said Braslow, who spends time researching the care and treatment of individuals with serious mental illness.
“Until the 1950s we would have never left those with psychosis homeless,” he said. “If there was no family they would go to asylums. Anyone who would need care, would get it.”
“For a psychiatrist of the 1950s, it would have been unthinkable not to intervene when an individual’s psychosis led him or her to homelessness,” Braslow said.
Braslow’s research suggests that former state hospitals and their staffs often managed to provide humane care. In California, state hospitals provided care for all who needed it regardless of ability to pay and provided a wide variety of therapeutic activities, ranging from occupational and industrial therapy to beauty shop therapy and bibliotherapy.
Why did the institutions go away? Many in California blame Governor Ronald Reagan, but the passage of Medicaid and Medicare legislation led to a dramatic decline in state hospital populations, according to Braslow.
In 1965, Medicaid and Medicare laws were passed. Disabled people living in the community were eligible for benefits, but those in mental hospitals were excluded.
In 1967, when Reagan was elected governor, the number of patients in state hospitals was about 22,000. He made cuts to the Department of Mental Hygiene and signed the Lanterman-Petris-Short Act, which meant that patients could not be institutionalized against their will or for indefinite periods of time. According to an NPR report, after the law was enacted, the number of people entering San Mateo’s criminal justice system doubled.
In 1969, Reagan reversed his position and increased the allocation for the Department of Mental Hygiene by $28 million.
In 1972, Social Security was modified so that payments could be made to individuals not living in a hospital, in order to encourage people to live independently. Medicare provided funds for the elderly to be treated in nursing homes rather than hospitals.
Medicaid also was designed to encourage states to move people out of hospitals and into smaller facilities. States could only be reimbursed for expenses if individuals were living in a facility with 16 or fewer beds.
According to Dr. Richard Frank, writing in the Journal of Psychiatric Services, the number of state mental hospital residents over the age of 65 fell from 153,309 in 1962 to 78,479 ten years later.
During that time the number of elderly people with mental disorders residing in nursing homes grew from 187,675 to 367,586.
In 1980, President Jimmy Carter signed the Mental Health Systems Act to provide federal funding to states for the mentally ill.
As president, Reagan repealed this act in 1981, pushing the financial responsibility of the mentally ill back to the states.
According to NPR in 2004, the U.S. Department of Justice estimated that 10 percent of state prisoners had symptoms that met criteria for psychotic disorder.
In the 2015 homeless count in San Francisco, “55 percent of people experiencing chronic homelessness report they have emotional or psychiatric conditions.”
If California and the City of Los Angeles are serious about helping the homeless, in addition to focusing on housing, politicians and officials must address treatment and payment of treatment for the mentally ill.
“The most heart-wrenching person we come into contact with is someone who is severely mentally ill… living in their own feces and urine and vomit and covered in lice,” Doctor Susan Partovi said in a Channel 4 story (“Skid Row Doctor Says Health Risk Fear Over Homeless Isn’t What It Seems”).
“Those are the people that break my heart over and over again… That’s why I say shame on our society for not taking care of them.”