A mentally ill homeless person is far from a shocking sight to anyone who lives in or near a metropolitan area. Wandering mendicants who suffer from psychiatric disorders are ubiquitous in most large cities, where they elicit little more than fleeting glances from the majority of passersby, who consider them just another (often irksome) feature of the cosmopolitan landscape. According to a recent article in the Los Angeles Times, the city has approximately fifty-five thousand homeless, and the L.A. Chamber of Commerce estimates Downtown’s Skid Row population as fluctuating between eight and eleven thousand. While many of the area’s residents are able to take advantage of local shelters and services, there is still a staggering amount of people who live life on the streets devoid of basic necessities like food, clothing, shelter and adequate medical treatment. How did this happen, let alone persist, in a country as prosperous as America?
It is undeniable that homelessness and mental illness are inextricably linked, yet in terms of American history, this is a fairly recent phenomenon – especially at the epidemic levels we are currently experiencing. A thorough examination of these two topics however, reveals the genesis of their confluence and why it provided the perfect storm in which to incubate (and give rise to) the tragedy it has become.
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Two events that took place near the middle of the twentieth century can arguably be blamed for the convergence of homelessness and mental illness. These events, fueled by a constellation of additional circumstances, sent society on an irreversible trajectory that has resulted in the explosion of the population of homeless people who struggle with mental illness.
They are:
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Fact: At some point in the 1950s more than half a million Americans were confined to state hospitals.
These giant compounds, featuring stately architecture and sprawling grounds were largely the brainchild of Dorothea Dix, tireless advocate for the humane treatment of the mentally ill. Originally intended as refuges for psychiatric patients, these institutions were lavishly constructed and beautifully landscaped. Their philanthropic developers hoped to affect cures for the residents by administering what was called “moral treatment.” This was accomplished by a steady diet of fresh air, nutrition and vocational activities. Unfortunately, rather than being “cured,” and released (as was the goal) many of the residents remained confined for the duration of their lives, even as the hospitals’ populations grew. Chronic hospitalization became a specific mode of treatment, and was very effective, as some people needed institutional support. Eventually funding lapsed, as did the qualified staff and the idyllic lifestyle they provided. The reputation of mental hospitals or “insane asylums” took a turn for the worse and they became synonymous with neglect, abuse and maltreatment. In 1948, a film called The Snake Pit increased public awareness about the deplorable conditions in state hospitals via the depiction of the main character’s experience in a fictional institution. Adding to the mix was a 1972 exposé conducted by Geraldo Rivera (then an up-and-coming reporter) and a fellow print journalist. The twosome gained access to the Willowbrook State School (which was operating as a mental health hospital) via the key of a disgruntled employee. Once inside, they videotaped the terrible conditions and shined a light on the abuse and neglect that regularly occurred there. Also fanning the flames was the film version of Ken Kesey’s book, One Flew Over the Cuckoo’s Nest, which was released in 1975 and painted mental hospitals in a terrible light.
As politicians struggled to overcome the negative images and financial problems caused by the failing mental hospitals, the pharmaceutical industry was on the cusp of introducing a new drug that held great promise for the treatment of the mentally ill. Unfortunately, when politics converge with medicine, the outcome is not always positive for society.
Anti-psychotic drugs were introduced into psychiatry in the 1950s, with the crowning achievement of the era being a drug called chlorpromazine, aka Thorazine. Now, instead of using sedatives merely as “chemical restraints” to put people to sleep, patients could take this drug and remain somewhat functional. So revolutionary was this medicine that it was awarded the Lasker Prize in 1957. The inscription on the award read, “for the introduction of chlorpromazine into psychiatry and for the demonstration that a medication can influence the clinical course of the major psychosis.” The Germ Theory about disease had been accepted by this time and the medical community now operated under the assumption that diseases could be improved or cured with specific treatments. Despite this new standard, there wasn’t much evidence to support the idea that the chlorpromazine was actually treating the illness. According to psychiatrist Dr. Joanna Moncrieff, it was simply inducing a “state of neurological suppression which reduced behavior disturbance as well.”
The disintegrating reputations of the state mental hospitals and the pressure to make drastic changes regarding their operation, combined with the advent of these new drugs lead to lawmakers’ desire to come up with a new plan. Despite good intentions, their remedy for this complicated issue was shortsighted and has resulted in many of the problems we are still dealing with today. Excessive enthusiasm on the parts of the medical establishment and elected officials was most likely due to the coalescence of poor clinical science and wishful thinking.
Armed with misinformation and backed by psychiatrists who over sold the idea, President John F. Kennedy signed the Community Mental Health Act of 1963. The legislation, which was supported by members of academia, medicine and the political community, was designed to integrate people with mental illness back into society. It was intended to provide federal funding for community health centers and research facilities that would treat patients locally while allowing them to work and live at home. This resulted in widespread deinstitutionalization and despite enthusiasm for the plan, many people returned to communities where there were no facilities in place to deal with them. Tranquilizing drugs like chlorpromazine became the panacea for the mentally ill. Unfortunately, this plan was never fully funded and only half of the proposed centers were ever built. Many states simply closed their mental hospitals without spending any money on community-based care. This led to legions of mentally ill homeless people.
Herein is where the concept of patients’ civil rights begins to intersect with the idea of enforcing treatment. On one side of the argument are the advocacy groups who wish to protect the civil rights of those who are mentally ill. On the other side are many members of the medical community who wish to treat patients, but are hamstrung because of the stringent civil commitment laws. Parents of mentally ill people are yet another faction who are frustrated because they cannot legally force their adult children to take prescribed medications, let alone insist on treatment. Many of them voice concerns about learning their child has done something terrible only when it’s reported on the nightly news.
Over the years, several states have made the effort to bridge the gap in order to protect patients without infringing on their civil rights. In 1967, Governor Ronald Reagan signed the Lanterman-Petris-Short Act into law. This allows police to take people into custody for psychiatric treatment if mental illness prevents them from meeting their own basic needs (food, clothing and shelter). Unfortunately, these holds are generally brief and don’t do much to actually treat the person. In 1999, the state of New York enacted Kendra’s Law, which gives judges the authority to issue orders that people who meet certain criteria regularly undergo psychiatric treatment or risk a seventy-two hour commitment. While these laws are a step in the right direction, they do not provide the sweeping reform necessary to protect both patients and their communities. The criminal justice system is tasked with jailing people who are ill and then releasing them back into society. According to the National Alliance on Mental Illness, a person who experiences a mental health crisis is more likely to come into contact with law enforcement than receive medical help. In fact, two million people with mental illness are booked into jail every year. The fact is that people who are mentally ill often do not realize that this is the case and when they improve, are angry at having been left to languish in their disease for so long.
Fact: There are approximately sixteen thousand homeless people suffering from mental illness in Los Angeles.
The city of Los Angeles has long been plagued with a homeless population that ebbs and wanes, but the problem has never been completely solved. Ground Zero for this crisis is a fifty-block area located downtown, known as Skid Row. To walk in this area is to encounter scores of homeless people who are mentally ill, addicted to substances or both. Shopping carts filled well past capacity are pushed by their owners or parked outside of tents, and “homes” made of cardboard and other refuse. The unmistakable odor of human excrement and urine floats in the air and garbage is everywhere. It is nearly impossible to not feel threatened by the area’s inhabitants, whose behavior is largely unpredictable. The prospect of approaching individuals who lie in makeshift shelters or lumber in the streets aimlessly is an intimidating experience, to say the least.
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Until the 1970s most of the people on Skid Row were able to live in cheap apartments or SROs (single room occupancy) hotels, but plans to raze and revitalize the area were afoot as early as the 1940s. In 1972, The Silver Book Plan proposed to create a center where the area’s indigents would be detoxed and “rehabilitated” within a few years. Afterwards, it was presumed that they would disappear back into the general population. Despite this rosy prediction, activists were slow to buy into the idea that Skid Row would cease to exist, arguing that the population would merely be displaced into other parts of the city. They proposed The Blue Book Plan. This was essentially a containment plan that included the benefit of pushing all the services for the homeless into newly drawn boundaries.
This plan was adopted in 1976 when, during the redevelopment of Bunker Hill, large numbers of poor people where forced out of the neighborhood. Low-income housing and services were concentrated within the confines of the fifty square block area known as Skid Row. While many of the area’s original residents supported The Blue Book Plan, they complained that specific things were done to psychologically discourage them from venturing outside the defined borders. Not only were necessities like food, bathrooms and showers available only within the quadrant, but bright lights were used to illuminate common areas in an effort to reduce illegal activities. Many complained that it was like living in a prison. Homeless people were routinely funneled there and the population grew even more in the 1980s due to the crack epidemic, Reagan’s War on Drugs and cuts to the welfare system.
In the 1990s and 2000s, Downtown Los Angeles experienced another wave of gentrification and it became a vibrant residential and entertainment hub. People who purchased expensive lofts and apartments didn’t want to deal with the ever-expanding problem. In 2006, Police Chief William Bratton dealt with the homeless by instituting the Broken Windows Campaign. This called for the issuance of tickets to homeless people for minor offenses. When they failed to pay their fines, they were arrested. Once they were released from jail they were deposited back into Skid Row.
2006 was also year that the American Civil Liberties Union took the city to court on behalf of homeless people who wanted the right to sleep on the street – and not just in Skid Row. According to the Executive Director in Southern California, the lawsuit was a way of asking the city to provide more shelter beds for the homeless and to permit them to sleep on the streets when they are full. In Jones vs. Los Angeles, the 9th Circuit Court of Appeals said that the enforcement of the city’s law against sleeping on the street was unconstitutional so the city agreed to not enforce it between the hours of 9am and 6am until 1250 more units of housing were constructed for the homeless. In June of 2018, Mayor Eric Garcetti declared that the conditions had been met and that the Jones Agreement was ending, however, the city is still abiding by it. Homeless people can still be found all over the downtown area.
Many medical and legal experts continue to advocate for legislation to expand the term gravely disabled (see last week’s article) in order to conserve people who cannot take care of themselves, make informed decisions, are suffering from addiction or are mentally ill. They argue that mental illness is a disease like any other and should be intervened upon and appropriately treated. On the other side, as always, are the advocacy groups who defend civil liberties and claim that people must consent to treatment rather than have it forced upon them. The barbarian tactics that were inflicted on people in decaying mental hospitals is certainly not the answer, but surely some intervention on behalf of the mentally ill is appropriate.
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Despite widespread awareness about these issues, many feel that they are far removed from these problems, so action is not urgent or mandatory, but this could not be further from the truth. These problems affect all of us. People in affluent neighborhoods from Beverly Hills to Santa Monica to Pasadena encounter homeless people on a daily basis. Issues range from dealing with the filth and human waste that the encampments produce to interactions that can become confrontational without warning. While upsetting, these experiences are actually on the mundane end of the spectrum.
Unfortunately, one of the many features of mental illness is the unpredictable nature and circumstance of how it is expressed. People who suffer from psychiatric disorders often engage in impulsive behaviors as a result of their inability to access proper care. Statistically, it is far more likely for a mentally ill person to be the victim of a crime than to perpetrate one, but the tragedy is somehow magnified when it becomes apparent that a spontaneous, but deadly act might have been avoided with the benefit of medical intervention. Kendra’s Law was enacted after a man who had been diagnosed with schizophrenia (but off his medication) killed Kendra Webdale by pushing her into the path of an oncoming train. In a case like this, the system failed both Kendra and the mentally ill individual who took her life. How many more senseless deaths must occur before everyone’s rights are considered equally?
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If this argument for action fails to resonate, consider Dr. Drew’s prediction from earlier this year concerning disease epidemics, and please note that they came to pass. According to Dr. Drew, that was just the beginning. The squalid living conditions that accompany homeless people with mental illness will undoubtedly give rise to more lethal epidemics – primarily by way of the infected rodents that will carry them into ALL populations – despite affluence, education and station in life. While the plight of the homeless may be far from our collective purview on a daily basis, be assured that deadly bacteria and viruses do not respect economic boundaries. Though the homeless will continue to bear the primary (and largest) burden, there is nothing to prohibit these diseases from affecting the general population.
A keen understanding of how these cycles come to pass has resulted in Dr. Drew’s belief that we are presently vulnerable to a number of epidemics. When large populations of wild infected rodents live side by side with humans, the transference of germs is inevitable. Rats, fleas, mites and ticks are all carriers of bacteria and viruses that can have devastating effects on the health of humans.
Diseases that originate from rats fall into two categories: directly transmitted (exposure to rat-infected feces, urine or bites) and indirectly transmitted (exposure to an arthropod vector such as fleas tics or mites).
Diseases that are transmitted directly by rats include:
Diseases that are transmitted indirectly by rats include:
In addition to an outbreak of the plague, Dr. Drew is particularly concerned about future typhus epidemics. Homelessness begets sanitation problems, and wild rodents are attracted to (and thrive in) unhygienic living conditions. Recently, Los Angeles experienced typhus outbreaks, but this illness is likely to make a comeback. There are two types of typhus. Epidemic typhus is caused by a bacteria called rickettsia prowazekii and is transmitted primarily by lice. Epidemic typhus means that a few animals (usually rats) via lice vectors, can incidentally infect large numbers of humans quickly when certain environmental conditions are met. Endemic typhus aka murine typhus is caused by rickettsia typhi or rickettsia felis and is transmitted primarily by fleas. Endemic typhus means that an area or region has an animal population (mice, rats, squirrels) that has members of its population continually infected with rickettsia typhi that, via flea vectors, can accidentally infect humans. These two illnesses have similar symptoms, which include rash, fever, nausea, diarrhea and vomiting, but epidemic typhus can also be accompanied by severe bleeding into the skin, delirium, hypotension and death. Small, localized outbreaks of endemic typhus are common in and near the foothills of Southern California. The outbreak in the summer of 2018 led to the notification of all physicians in the area that a serious outbreak was underway.
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Homelessness and mental illness often go hand in hand. Over the last century or so, the deterioration of the mental healthcare system has resulted in many psychiatric patients becoming homeless with no prospect of being rescued. Changes must be made towards giving healthcare professionals the ability to treat these people, many of whom are so ill that they have limited or zero awareness of their dire circumstances. Loss of insight is a feature of these psychiatric illnesses. Time and again, parents or relatives of adults with mental illness find themselves helpless when it comes to administering medications and enforcing psychiatric care. All too often what begins as a costly emotional expense ends in tragedy. The definition of “gravely disabled” must be expanded so as to provide conservatorship for those in need. Unfortunately, it has been the habit of our society to consider mental illness differently than other medical problems and physiological illnesses. It would be unthinkable to allow a homeless person to suffer a heart attack or physical injury without medical intervention, yet that is precisely what we do when it comes to mental illness. This disconnect needs to be addressed.
We must recognize mental illness as a disease and treat it as such, or we will all eventually be impacted for the worse. The toll that continued ignorance of this problem will exact on society is simply too high.
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