(February 6, 2019) The Treatment Advocacy Center's latest report, A Promising Start: Results From a California Survey Assessing the Use of Laura's Law, assesses the implementation of Laura's Law, California's version of assisted outpatient treatment (AOT). AOT is a tool to engage individuals into treatment who have a history of nonadherence, and who often lack insight into their illness. In California and elsewhere, severe mental illness is common among homeless individuals, prevalent in at least one-third of single adults who are chronically homeless.
This week’s Research Weekly is written by Susan Partovi, MD, the Medical Director of Homeless Health Care in Los Angeles, California. Dr. Partovi is a street medicine physician. She treats patients throughout the city who are homeless, meeting them and providing medical care where they are living on the streets. Going beyond the financial and political aspects of A Promising Start, Dr. Partovi sheds light on the people behind the data—those suffering from severe mental illness—providing real evidence for the need to change the status quo.
Behind the Muddied Glass
by Susan Partovi, Medical Director of Homeless Health Care Los Angeles
I met, let’s call her “Carrie,” on a Wednesday. She had no clue what day it was. Carrie was in her mid-50’s.It was my first day doing mental health rounds with a team of mental health clinicians and psychologists. I’m a family physician and used to work part-time at the Los Angeles County women’s jail. I have been the go-to “medical” physician for mental health clinicians when they suspect their patients may be physically ill as well. I have years of experience working with people with severe mental illness, spending the last 15 treating the homeless both in clinics and on the streets. People with severe mental illness, especially in the streets, have broken my heart time and time again.
Carrie was no different. I think I gasped as I looked at her clinician who came to the jail cell window with me. Carrie was naked, refusing to wear her jail clothes, and quite thin. She hovered over toward us looking out through the muddied glass. But it wasn’t mud. She had streaked feces over the glass and all over herself.
“Ms. Carrie? Hi. I’m Doctor Partovi. I’m here to say ‘hi’ and see how you’re doing.”
She was bent over, intently reviewing a make-believe board, “A, B, C. That goes in A, then you go in B,” she rambled, preoccupied with whatever was in front of her.
“Ms. Carrie, do you take any medications?” I ask, trying to get her to acknowledge me.
“Yes, the vitamins go in A, but what about B...?” She sticks to her project. I noted that she was alert, able to move her body well, but that was about it. The clinician and I returned to our group and the psychologist asked, “That bad?” We both shook our heads as I fought back the tears. “She’s our number one then,” the psychologist announces. “Number one” means she is the first one to be sent to the LA County Jail Psychiatric Hospital when a bed opens up. Luckily, she was sent later that day. I knew she would get good care at the jail psychiatric hospital because they are allowed to medicate and hospitalize involuntarily. Almost magically, patients often become remarkably better after a few days of medication and then agree to take their medications on their own.
How did Carrie end up here? I truly doubt that she is a criminal endangering others. I never inquire on why the inmates are in jail, but I can imagine.
This story is not about how horrible the jails are to the mentally ill…on the contrary, I’ve been impressed with how caring custody staff and the mental health clinicians are with this population. We all know people with severe mental illness do not belong in jail and most people that work with this group try to make it as easy as possible for them. But it’s still jail. They are in a cell. It’s the perfect storm for someone who normally can’t deal with daily life, to explode into a full psychotic episode. So, why is Carrie (and more than 20% of the Los Angeles County Jail population) in jail and not, say, at home with loved ones, or in a facility where she is being helped to eat and dress and enjoy life with the support of professional caretakers?
The county now has programs that can divert people like Carrie into full time care, which is what she needs. But why didn’t this happen before potentially petty crimes sent her to jail? Why didn’t we take care of her before she spiraled out of control or before we spent tens of thousands of dollars on legal fees, court fees, custody overtime, psychiatry, psychology, clinicians, a hospital and me? We, as a society, are operating under the belief that Carrie wants to be homeless, suffer from paranoia and hallucinations, and be naked in a cold cell using feces as an art vehicle. As a result, the number of homeless individuals with severe mental illness sky-rocketed and the number of mentally ill inmates soared.
It costs more money to care for those on the streets than to provide them with the humane care they deserve. In fact, it can cost up to $100,000 per year to care for a homeless person in medical and legal costs. A recent study shows that those who live on the street are ten times more likely to die. But before they die, they spend a lot of time in emergency departments and hospitals. Furthermore, those with severe mental illness, chronic medical conditions and drug use are the most vulnerable for dying on the streets.
If I had seen Carrie in the streets, covered in feces and talking to hallucinations, allowing herself to be exposed to the weather, infestations, and possible illness, it would be near impossible to hospitalize her involuntarily. A hospital stay would promote stabilization and eventually housing that is best-suited for her needs. But if she steals a bag of chips, the criminal justice system takes over, and reduces the chances that she will ever get the help she desperately needs.
Dr. Partovi’s story reaffirms our reasoning for conducting the Treatment Advocacy Center’s county-by-county analysis of Laura's Law. As the title suggests, A Promising Start, found that Laura's Law is helping to provide services for people enrolled in the program, while helping to decrease psychiatric hospitalizations, crisis contacts, incarcerations and homelessness. But there are still large gaps in participation and in reporting. That means the people in the throes of psychosis – people like “Carrie” – are falling through the cracks of a system in need of reform.
Elizabeth Sinclair
Director of Research
Treatment Advocacy Center