On Skid Row, the mentally ill struggle through life with varying degrees of effectiveness. Some manage to find food and warmth at nonprofit shelters for the homeless. Others sleep in doorways and go hungry.
Some try vainly to cope with their paranoia and hallucinations by taking street drugs. In the worst cases, they keep only tenuous contact with reality; tattered, confused, they wander listlessly or step out into the streets in front of traffic. Some become so disoriented or physically ill they cannot communicate their own names or where they are from.
If they receive help--and the “if” is a large one--it is often because of Karen Palermo and the five-member Psychiatric Mobile Response Team she supervises on behalf of Los Angeles County.
For two years, Palermo has run the team from the sparsely furnished offices of a county mental health clinic at 6th and San Pedro streets. Along with her colleagues, Palermo is in charge of handling psychiatric emergencies in a wide swath of downtown extending from Skid Row into East Los Angeles and Hollywood.
She learns of crises by taking reports from residents or relatives of the mentally ill. Her task is then to travel to the scene--sometimes in private homes, sometimes on the streets--to conduct on-the-spot psychiatric evaluations.
If the individual is judged to be dangerous to himself or to others, Palermo exercises legal authority to order a 72-hour protective hold. Usually the subject of her evaluation is then whisked away by ambulance, sometimes with the aid of police, so that further psychiatric testing can be done. Often, the person is routed into a mental health program or to a psychiatric hospital bed--if one is available.
Palermo’s team has faced an escalating workload even as dwindling budgets have forced significant cuts to county services. Last year alone, five county-run mental health clinics were closed and others lost substantial manpower. Existing clinics now have waiting lists of would-be patients. Further proposed cuts threaten the closure of 19 more clinics, a move that would leave 27,000 mental health patients without care, county officials estimate.
A few years ago, teams such as Palermo’s operated on a 24-hour basis, with workers carrying beepers at night. Today, they must allow police untrained in handling psychiatric disorders to step in when crises occur after hours.
Q: We hear that the county mental health system has declined significantly. How much worse is it now than five or 10 years ago?
A: It’s obviously worse in a number of ways. Ten years ago, we didn’t have as many ethnic communities. Those are growing, which means you need more specialized ethnic care. We also had a better budget 10 years ago. Over the last four years, the governor has decreased our (county mental health) budget by $14 million. You have to add in a 4% to 5% inflation rate during that time. Our budget is now at somewhere near a $43-million deficit.
We’re stretched in more directions than ever. We have a large homeless population. If you go out in the streets you can see that. Ten years ago, there were more state psychiatric hospital beds. There’s a limited number of beds now, so that puts more patients out on the streets.
Q: Is it an overstatement to say the mental health system is falling apart?
A: No, I don’t think so. If these anticipated (budget) cuts go through and the Board of Supervisors does not give us some extra funds, we will not have a system. With the cuts it has been estimated that 20,000 of the patients we now serve (in Los Angeles County) will lose service. We’ll be cut down to 49,000 clients--people who receive medication, day treatment, outpatient therapy, hospitalization. . . . The rest of those people will go without. A wide variety of services are no longer being offered. The system is really just teetering right now.
The problem really goes back to the de-institutionalization of mental patients in 1959 with the California Community Service Act. That basically said mental patients should not be in state hospitals any more. There should be resources out in the community to mainstream them back into society--board-and-care homes so they have a place to stay, day treatment programs, vocational rehabilitation programs, outpatient medication programs.
It was a beautiful model . . . except for one thing: Along with it there should have been mandatory funding to take care of these people.
Q: What kinds of problems do you see here on the streets of Skid Row?
A: It’s very sad. What we see downtown are a lot of the homeless--severely mentally ill individuals who basically have no resources to help them. If they are not committing a crime, LAPD is not going to be involved with them. Particularly now, with the cold weather coming on, a lot of them are out on the streets. They’re freezing. There are cold weather shelter programs, but a lot of them, because of their mental disability, are too paranoid or too gravely disabled to try and find those places to keep themselves warm.
Q: Do county studies indicate what percentage of the people on Skid Row are believed to be mentally ill?
A: Upwards of 33%, or more.
Q: What does your team do in dealing with these people?
A: We go out and do an evaluation. We see what their level of functioning is, and if they’re competent to make the decision to live on the streets. Can they get shelter when they need it? Can they get clothing? Are these people going to starve or die or whatever?
Maybe they’re a little unstable but not enough to require hospitalization; then we try to give them alternatives . . . help them get clothing, shelter, that kind of stuff. About half the time, we can get them off the streets. Other times, no, they don’t want to hear about it.
Q: What happens with those people?
A: You see them in the medical emergency rooms around here. One example was an old woman we dealt with recently living in the area a little west of downtown, in the bushes. She was out on the streets and it got too cold for her. She ended up with a hypothermic reaction. The police found her; she was almost frozen. They took her to Good Samaritan. She got pneumonia. When that starts happening, it puts a real financial burden on the ERs.
And others don’t make it. Some of them do die, unfortunately.
Q: What about the drug problem? You hear a lot about the use of street drugs on Skid Row. Does that make it more difficult to determine who is mentally ill and to decide what kind of treatment they need?
A: Yes, the drug problem is something we deal with all the time. The first thing we want to know when we’re screening a person is, ‘Is that person using any particular kind of drug?’ You may have some idea by looking at the eyes. Are they constricted? Are they very dilated? Or by looking at the arms. Do they have track marks?
There are a lot of individuals who, because of their severe depression, use a lot of speed. They try to self-medicate. In that type of case it just exacerbates the illness. You’ll find them out in the street directing traffic, or becoming so irritable because of drugs that they threaten other people and become almost homicidal.
Q: Are very many of the people you see on the streets dangerous?
A: Oh, yes. They say the County Jail is the largest mental institution in the country, just about. It’s true. A lot of them lose control, have difficulty with impulses, and they get into trouble. . . . A lot of these people, if they don’t get their treatment, they become very paranoid. They feel like somebody’s going to attack them. Then they will attack first.
That’s one of our arguments. If you cut (funding for) mental health . . . you’re going to have to give the money to county jails; you’re sure going to have to give it to the courts and you’re going to have to beef up LAPD because these people do not disappear. They do not go away. They just go somewhere else and some other system has to deal with them.
These people die, they kill themselves or they kill other people.
Q: How dangerous is the situation for you and your team?
A: We have to be careful all the time. One of the scariest things that happened recently was a time when we were going out to evaluate an older man who was very unstable and harassing the kids in the neighborhood. Just hours before we went out he took a shotgun and just started shooting the windows and the roof of the house and LAPD was called. Had we been there it might have been us. . . . If there is any doubt about weapons or the possibility of violence we’ll call the police and have them go along with us.
Q: How much has the mentally ill population of Skid Row grown over the years?
A: Quite a bit. Personally, I cannot walk down the street here without stepping over one of them. I can’t remember that six years ago.
We found one gentleman a couple weeks ago right near Temple and 3rd streets. He was in the bushes with his thumbs in his mouth, filthy, and curled up in a fetal position. Well, no one had called us about him. But he was, in our estimation, ill enough that he wasn’t going to be able to protect himself; he wasn’t going to be able to find shelter.
There are just so many like that. Sometimes other cities will send their mentally ill out here, just put them on a bus. . . . Sometimes people will come out here because they have delusions that they’re going to be in the movies, or that Michael Jackson’s calling them. They think they’re going to come out here because the stars love them and are going to take care of them.
Q: What eventually happened with the gentleman you found at Temple and 3rd?
A: Well, the day after we picked him up I went to see him at the hospital and he was clean, his hair was washed. We got his name. Most of these people are Jane and John Does, but he could tell me his name and where he was born. . . . The last I heard they were trying to get him into long-term placement (at a board-and-care home).
That kind of gives you a lift.