Treating and housing the mentally ill is harder than jailing them. But it might actually work
By The Times Editorial Board
Feb 28, 2018 | 4:15 AM
If only we could make Les Jones’ story more commonplace.
As the 62-year-old Texas native leans back from his desktop computer in his small apartment, he details his journey from a successful radio career to a mental breakdown, to the streets, to shelter and finally to treatment and a healthy, happy life in this tidy complex at perhaps the most enviable corner of Santa Monica, steps from the Third Street Promenade, a short walk to the beach.
“I am one verse,” Jones says of the composition of the American population of the mentally ill. “There are others. Modern treatment of mental illness produces miracles. It literally saved my life.”
Jones lives at Step-Up on Second, the name of the apartment building and the nonprofit organization that operates it. He is serving his second stint on Step-Up’s board of directors, runs a computer-training program and helps other residents adjust to their new home.
He has lived here 11 years.
This is permanent supportive housing. This is the type of thing Los Angeles voters are helping to build through their ballot measures and tax dollars. Jones and his neighbors each have their own apartments and lock their own doors. They visit on-site counselors and clinical staff as needed and discuss their progress, their lives, their medication. Many leave each morning for jobs.
Their lives are the promising future that policymakers and mental health professionals envisioned beginning in the 1950s, when a drug that was first developed as a sedative for surgical patients began being prescribed in psychiatric institutions and completely changed the nation’s approach to mental health. It was marketed under the name Thorazine.
It was the age of medical miracles: antibiotics like penicillin, and vaccines and treatments that virtually eliminated polio, smallpox and diphtheria. Drugs could cure almost anything. Surely they could cure mental illness.
Modern treatment of mental illness produces miracles. It literally saved my life.”
That post-war spirit of can-do optimism contrasted with the barbaric mental health treatment of the time. In state hospitals and asylums, staff had responded to behavioral problems with tranquilizers or, in far too many cases, abuse that verged on torture. Patients were often force-fed and treated like prisoners, which in essence they were. That was to change.
The last bill that President Kennedy signed before his assassination in 1963 was the Community Mental Health Act — a landmark law to fund and build community mental health centers. The old-style state hospitals and asylums would close and patients would come home to be treated in outpatient clinics, in supportive-housing communities, or in local inpatient hospitals. In 1967, California adopted the Lanterman-Petris-Short Act, which strictly limited forced hospitalization and the involuntary medication of patients.
This was deinstitutionalization, and the word had positive connotations. Civil libertarians supported patients recovering their self-determination. Others applauded the cost savings that came from treating people in outpatient settings. The mental health establishment — much of it anyway — expected better psychiatric outcomes and an end to abusive conditions.
So what happened? Why do so many people with mental health challenges end up on the street instead of community clinics? Why are there so few success stories like Les Jones, too few places like Step-Up on Second and far too many people in Los Angeles and around the nation today who turn to street drugs like heroin instead of prescribed medication to quiet the voices in their heads, or to methamphetamine to try to ease their depression?
First, it’s important to remember that the mentally ill account for only about a third of the homeless, so even if they were all properly treated and housed, homelessness would remain a monumental problem in Los Angeles.
That said, people who should be in permanent supportive housing and clinical care are on the street in large part because a society that did so well at the easy and money-saving part of deinstitutionalization — releasing the patients, laying off the staffs, closing the hospital doors — failed to follow through with the difficult and expensive part. Few of the promised clinics were built. The funding was constantly delayed. It was finally supposed to come with the Mental Health Systems Act of 1980, signed into law by President Carter. But the following year, Congress and the new president, Ronald Reagan, repealed the act.
Without a Home
They’re part of the Los Angeles streetscape, as familiar as the swaying palm trees and idling traffic, living under freeways, alongside riverbeds and on canyon hillsides. The mentally ill, the drug addicts, the economically disadvantaged, many with their life belongings in a backpack or shopping cart. In this ongoing series, Without a Home, The Times is examining the crisis of homelessness in our region. Full coverage
Meanwhile, medication was not the quick and easy solution that it had been made out to be. Thorazine had serious side effects. It was replaced by a variety of other drugs, many of which do work wonders — as is the case with Jones, who says his treatment keeps his schizo-affective disorder under control. But many patients complain they are no longer themselves when medicated.
With a dearth of clinics and supportive housing and little public appetite to pay for them, cities, counties and states have had to scramble for their own solutions.
Many defer to nonprofit shelters, which offer meals, drug counseling, medical referrals and job training. It’s the right answer for some. Jones began his journey to recovery at such a shelter. But others battling illness or substance abuse are deterred by the strict rules of conduct or by the bans on personal belongings or pets. Bureaucratic mazes that would deter even the most emotionally fit keep mentally ill homeless people from seeking help.
Jones was lucky enough to have a place to go. If everyone on the streets could look forward to the same positive outcome, it might be easier to open more places like Step-Up on Second. But many nervous would-be neighbors fear that most mentally ill homeless are unlike Jones and could never integrate safely into a community setting.
Some mental health professionals and elected officials believe the answer is to roll back laws that limit the ability to forcibly commit people who can’t or won’t seek help on their own. The L.A. County Board of Supervisors recently called for just such a change, presumably to deal with people whose conditions are too serious for permanent supportive housing. There are now bills in Sacramento to amend the Lanterman-Petris-Short Act’s protections against compelled treatment.
In 2001, The Times editorial board published a series arguing that it was indeed worth sacrificing some civil liberties in order to treat people, rather than permit them to die on the street. But the issue isn’t all that simple. Today, The Times cautiously supports re-examining existing laws on compelled treatment, as long as Californians do not mislead themselves into believing that it is an acceptable, effective or lasting shortcut for getting a majority of people with mental health challenges off the street. For all but the most seriously ill, the better answer is a painstaking process of trust-building. Otherwise, sick people who are run through a ponderous and liberty-depriving process will just drift back to the street. For many, successful treatment requires housing first, so that patients can drop their perpetual guard against assaults on both their personal safety and their self-determination.
Besides, forcibly committed people would still need a place to be housed and treated, and we are still without the clinics and other facilities that were supposed to come with deinstitutionalization.
By default, and to our collective shame, much of the response has been a virtual reinstitutionalization — but this time, to jail.
The largest psychiatric institutions in the United States are the Los Angeles County jails, the Cook County Jail in Chicago and Rikers Island in New York. L.A. County incarcerates thousands of mentally ill people. The Sheriff’s Department reports that more than 70% of inmates who enter jail report a serious illness, either mental or physical. The county is moving forward with a $2-billion-plus plan to replace the aging Men’s Central Jail with a new facility specifically geared toward mental health treatment — but still a jail. We’re back where we started, but this time even more literally than before: Mentally ill people are prisoners.
It’s not that jailers want the new business. It’s a population, L.A. County Sheriff Jim McDonnell recently told ABC7, “that I would argue should not be treated in a jail facility.”
Making jails the centerpiece of mental health treatment is a monumental betrayal not just of the mentally ill, but of the forward-looking thinkers of the 1950s and ’60s who saw a path toward a more humane and civilized society. And it is inefficient as well; treatment in jail costs more than treatment in clinics.
Los Angeles County government recently reorganized itself to recognize and respond to mental illness, addiction, criminal justice and homelessness in an integrated fashion. Now voters have approved a housing bond and raised their sales taxes to address homelessness.
It is perhaps a thin wafer of a down payment on the long-promised funding for community mental health treatment. But the money is just the first step. Few people enthusiastically welcome permanent supportive housing to the neighborhood. Fewer still accept mental health day clinics.
So the misery on the street grows, even though, for many people, places like Step Up on Second would be a godsend.
Jones tried to explain that recently when going door-to-door to calm the fears of neighbors to a soon-to-be-built Step Up project.