Homelessness, Prisons, and Mental Illness

 

The problem of homelessness in the United States has finally been getting more attention lately. A big part of this population has a chronic severe and persistent mental illness like chronic schizophrenia. Not only that, but a lot of these mentally ill folks are now in jail instead of mental hospitals. As I have previously mentioned, the largest mental hospital in the country is LA County Jail. They have usually been arrested for petty nuisance “crimes.” Private for-profit prisons are only happy to have these folks to increase their inmate population and their profits.

Digging a little deeper, as did author Lynn Nanos in her book Breakdown, the problem of what to do with these people seems almost impossible to solve. There is a shortage of hospital beds, and therefore patients pile up in emergency rooms with no place to go. Many people who have schizophrenia have no insight and don’t think they are mentally ill, and refuse treatment. 

Hospitalizing patients involuntarily has become highly controversial, with so-called “patients’ rights” advocates, some of whom don’t believe schizophrenia is a real mental illness, helping to change the criteria for involuntary treatment so that many who used to be hospitalized no longer meet the criteria.

Even if patients agree to treatment and a hospital bed can be found, there is no place to send them after discharge, and many return to the streets. There are very few places in which they can receive outpatient treatment, so they often go off medications and end up just where they had started.

On the street, homeless mentally ill persons who create a disturbance are evaluated by policemen who don’t know how to evaluate them properly but arrest them instead. They usually have no money and cannot bail themselves out.

The idea that this problem is insolvable is ironic because, when I started my psychiatric residency in Los Angeles in 1974 and throughout the following decade or two, the problem was solved! Let me tell you how. The Lanterman-Petris-Short Act of 1967 in California helped stop the many patient abuses that occurred in previous years in mental hospitals, such as families putting away relatives for endless hospitalization for various motives, some of which were nefarious. 

With the act, you could no longer hospitalize patients involuntarly endlessly. The longest you could hold them against their will was 17 days (28 if they were actively suicidal), with patients having the right to judicial review within 72 hours. Many of the details in the bill were then adopted in states across the country,

Back then, an individual could be hospitalized involuntarily if they met the following conditions: they obviously had to have a diagnosable mental illness. Then they had to be a danger to themselves, a danger to others, or gravely disabled. This last term meant that they could not provide for their own food, clothing and shelter. And this included patients who were living in cardboard boxes on the street, which at the time the bill was passed were relatively rare for reasons I’m about to describe. Now, because of patients’ rights idiots, that no longer is the case - it seems like someone practically has to be starving to death because of their illness in order to qualify.

Policemen back then seemed to know enough about mental illness to triage people they took into custody to psychiatric emergency rooms, which have now themselves become rather rare. We had a great one when I first moved to Memphis in 1992, but it was eventually destroyed by the business types who, as is now more common than ever, wanted to transfer the funding to their own pockets. 

Memphis also had a training program in mental illness for police, who formed what was called a Crisis Intervention Team or CIT. They were trained by psychiatrists and psychologists including me. The CIT model was later adopted by police forces across the country. It still exists here in Memphis. The problem is there are very few psychiatric emergency rooms to bring them to, and the medical emergency rooms not only can’t handle them but have no hospital beds to which they can send people.

Since psychotic people, unlike in the past, became treatable with medication so they could be released, state hospitals began to downsize. But they still had beds available. In LA, Camarillo and Metropolitan State hospitals were still in business. Patients in ER’s could be sent there, or to a county psychiatric hospital, or to some private hospitals that still had psych wards and contracted with the county. I worked at a private hospital that did this after my residency. This all began to change in the Reagan administration when states began to close the hospitals.

After discharge, programs were in existence to greatly reduce the odds of re-hospitalization. Patients who were unable to work because of their illness could be put on social security disability (SSI). This would then pay for housing for them in numerous “board and care” homes -  which seem to be disappearing for the most part. According to the Los Angeles Times, an estimated 142 facilities in California closed in the first quarter of this year alone with a loss of 3057 beds. 

Reagan tried to kick people with schizophrenia off the SSI roles because he didn’t believe in mental illness (Karma: he later developed one himself, Alzheimer’s disease). The courts eventually stepped in to stop him.

And the biggest difference from now is that there were a whole lot of community mental health centers we could refer them to for treatment after they were discharged. These now seem to be disappearing at a frightening pace. 

Politicians used “tax cutting” ideology to basically defund them, although the tax money often went to one of the politician’s own pet projects. We used to have several community mental health centers here in Memphis when I first moved here, which no longer exist.

Amazing how we had next to no homeless mentally ill patients in Los Angeles and Memphis back them. Problem (was) solved.