By Susan Partovi
I met “Carrie” while making rounds at the Los Angeles County women’s jail with a group of mental health professionals.
A woman in her mid-50s, she had no clue what day it was.
Naked and thin, Carrie ambled over, peering through the muddied glass of her jail cell. But it was not mud on the glass. She had streaked feces on it, and all over her body.
“Ms. Carrie? Hi. I’m Doctor Partovi,” I said. She bent over, fixated on an imaginary circuit board.
“A, B, C. That goes in A, then you go in B,” she muttered.
“Ms. Carrie, do you take any medications?” I asked.
She replied, “Yes, the vitamins go in A, but what about B…?!?”
Whenever I encounter people with severe mental illnesses they break my heart. Carrie was no different. I fought back tears.
One of the group’s psychologists asked, “That bad?”
“She’s our number one, then,” the psychologist announced, indicating that Carrie would be sent to the jail’s psychiatric hospital as soon as a treatment bed became available.
There are now fewer psychiatric hospital beds in the United States per capita than at any time since the 1850s, but by a stroke of luck, Carrie was placed later that day. She would receive the care she needed and deserved.
Some people with severe mental illnesses like schizophrenia and bipolar disorder need to be involuntarily hospitalized and medicated. Most become remarkably more lucid after a few days and voluntarily accept prescribed medication. Their responsiveness to treatment underscores my belief that they do not belong in the correctional system.
The mental health clinicians I know strive to provide compassionate care for people like Carrie behind bars, but there is only so much one can do. Jails create a perfect storm for someone with a severe mental illness. Being locked in a cold cell with one’s hallucinations only invites further psychiatric deterioration.
However, we have created a system in which the severely ill – people like Carrie – are incarcerated, in part, because they have nowhere else to go.
At least one-third of chronically homeless adults in California now have a severe mental illness, along with more than 20 percent of inmates at the Los Angeles County Jail. Many are there for petty offenses, like stealing a bag of chips.
Society also seems to operate under the false assumption that Carrie wants to be homeless, accepts her paranoia, and decides to stand naked in the cold, smeared with feces. No. These are unwelcome symptoms of non-treatment, not rational choices.
Had I encountered Carrie in the streets, talking to her hallucinations while exposed to the elements, it would have been nearly impossible to hospitalize her involuntarily, even though a hospital stay would promote stabilization. That is shameful.
On the streets, the homeless with severe mental illness are more susceptible to drug use, other chronic illnesses, and outbreaks of medieval diseases. According to one study, they are ten times more likely to die.
Meanwhile, when they seek refuge in emergency departments and hospitals or cycle through the criminal justice system, the per person service costs to taxpayers can reach $100,000 per year – more than the cost of comprehensive care in an inpatient facility.
California, and Los Angeles County, in particular, has programs that can divert the Carries of the world into full-time care before tragedy ensues. But it does not necessarily utilize them effectively.
Laura’s Law, for example, is the state’s version of assisted outpatient treatment – a tool to engage individuals into treatment who have a history of non-adherence to medication, and who often lack insight into their illness.
When the Treatment Advocacy Center assessed the implementation of this important program, it found that its services helped decrease psychiatric hospitalizations, crisis contacts, incarcerations, and homelessness. One might presume local governments would eagerly implement it with vigor. Yet a version of Laura’s Law is available in only 20 of California’s 58 counties, most of which underutilize the tools available under the law.
To stop people like Carrie from falling through the cracks of our broken mental health system, we need to change our approach. Until we do, our collective futures will remain obscured by muddied glass.
Susan Partovi is Medical Director of Homeless Health Care Los Angeles. She has provided medical attention to the homeless in the streets and clinics of Los Angeles for fifteen years.