I first met Barbara in 2014 when I started going out onto the streets of LA’s skid row. She stood out to my team and me because she was an older woman living by herself in the thick of skid row’s heroin “district.” She had long dreads and always greeted us with a shy smile, as if she were embarrassed of her overlapping front teeth.
She was willing to talk to us, but not willing to come to the clinic only a few blocks away. “Who would watch my stuff?” Barbara would say. She always stayed within feet of the same corner on 6th and Stanford, sitting, surrounded by loads of … her stuff. She didn’t have much to say, but would always say that she was “fine,” and would ask for cream for her skin and pain pills for her arthritis. I didn’t suspect much of a serious medical condition, but she obviously wasn’t able to take care of herself.
The legal definition for Grave Disability in California is someone with a mental disorder who is unable to provide themselves food, clothing or shelter. She met the legal definition of Grave Disability for California: She was unable to maintain a safe shelter environment. She had a makeshift dwelling of a cardboard floor and a tarp for a roof and eventually had her own tent like the rest of skid row inhabitants. But she was exposed to the cold in the winter, the heat in the summer, predators, vermin and illness.
One of my teammates found out that she used to live in the hotel across the street but many years ago was kicked out for hoarding and being unwilling to maintain a livable apartment. She didn’t go very far. As the outreach team became more housing oriented, she was given the grandest prize I could think of … an apartment at the beautiful Star Apartments a few blocks away.
She wouldn’t go and she couldn’t tell us why.
The Skid Row Doctor
I’m a Family Physician who specializes in Street Medicine—yup, I take care of patients in the streets. Street Medicine is where a group of people such as social workers, mental health clinicians, medical clinicians, nurses and outreach workers look for the most vulnerable “rough sleepers” and attempt to woo them into being cared for, whatever their needs may be.
The ultimate goal is to have them housed with the support they need to stay healthy and happy.
“But why should we care if Barbara (and thousands like her) is living in the street, if that’s her wish?” some might wonder.
Because she could easily be a family member. I think about my mom. I wouldn’t say she was severely mentally ill, after all, for decades she was a high school English teacher for the Los Angeles Unified School District. We had a strained relationship, both when I was growing up and when I was an adult. She was cantankerous, selfish and often mean. Moreover, she would lie and was a hoarder.
‘Had she been alone, she very likely would have deflected attempts at help.’
As she aged, I noticed she began to repeat herself, often telling the same stories over and over again. One day, I got a phone call that she had fallen and broken her arm and was taken to the hospital. She required surgery and while in the hospital, it was quite evident that my mom had severe dementia. It became even clearer when I went to her house and noticed the mess—unpaid bills and taxes and rotting food.
That was in 2009. When I completely took over her care, she had 24/7 live-in caretakers and ultimately lived in a group home until her comfortable death.
She had slowly deteriorated over the years to the point where she didn’t know her address, her age or at times my name. Had she not had me to step in, she would have lost her condo (she was months away from losing it due to unpaid taxes) and would have most likely been forced to live on the streets.
Though she had dementia, she was feisty and didn’t like being told what to do and hated being treated like a child or even more being touched. Had she been alone, she very likely would have deflected attempts at help. Despite my issues with my mom, I would never allow her to sleep in a tent exposed to the horrors of homelessness.
I don’t care how much she would have protested. She could cuss me out, hit me, whatever she wanted to do; I would never allow her to be homeless. It wouldn’t be OK with my soul.
And again, why do I care about Barbara? Because I see Barbara as my mom? Or maybe she is someone else’s mom. It just isn’t OK with my soul.
Categories of Mental Illness and Associated Help
Although Barbara had some mental illness, she didn’t seem to be delusional or talk to people who weren’t there. I suspected instead that she had dementia. I asked one of our outreach nurses to do a dementia test on her and she scored very low. Because she had refused housing, the outreach workers had lost hope of getting help for her. I had changed positions and wasn’t doing outreach anymore either, so she was no longer on my radar.
A couple of months prior to writing this piece, one of my outreach nurses from back in the day texted me saying that Barbara was admitted to her recuperative care facility. Recuperative care facilities are specifically for the vulnerable homeless as transitional housing while looking for something more permanent. The outreach team had seen a window of opportunity; the guy that “helped” Barbara out on the streets, now had cancer and was offered admission to the same recuperative care facility. Now, Barbara was willing to go with him.
At the time, I was working with L.A. County’s Department of Mental Health (DMH) to create a Street Psychiatry program to work with the Gravely Disabled on the streets. I called Dr. Jones (a DMH psychiatrist) and told him about Barbara. A few days later, we met her at the facility.
It was now more obvious that her inability to care for herself was due to dementia. A week later she was accepted to a locked board-and-care facility. My colleague sent me a video of her playing with other home-mates passing a big beach ball back and forth and laughing.
Now, the medical community, without any pushback often easily accepts dementia as a condition in which people need a very high level of care and shouldn’t be able to leave a facility for fear of danger of harm to self.
However, people with severe mental illness are discriminated against. We have accepted that psychiatric illness allows for rational judgment, but, in fact, psychosis doesn’t. Every psychotic homeless person by law qualifies as Gravely Disabled, which by law calls for immediate action. Hospitalize, stabilize and support them to live a life of peace, purpose, comfort, safety and joy.
‘I purport that all psychiatric illnesses should be seen in the same light as a “medical illnesses,” which cause one’s inability to care for oneself.’
But there is no funding stream for crises stabilization, step-down stabilization or residential housing for those with mental illness. Each county has to pay for all of the above. Neither Medi-Cal nor Medicare covers this. I am working on a bill (SB 1446) with State Senator Henry Stern (D-Los Angeles) to say that those with severe mental illness have the “right” to treatment and housing, similar to those with intellectual disabilities.
People with intellectual disabilities can receive up to $9,500 per month from the state for residential living with 24/7 staff. Those with severe mental illness get about $1,000 per month from Supplemental Security Income. Thus there is no incentive for the private sector to provide quality residential facilities, and hospital management tends to think that if there isn’t anywhere to place people, why hospitalize them only see them to go back to the streets?
If they do deem someone as Gravely Disabled and able to be conserved, the hospital will “house” them until they find a locked facility for them, which can take up to nine months. All that time, the hospital will be housing them without getting paid. So, hospitals raise the bar for who they think “really” needs to be conserved or hospitalized. County hospitals don’t work in the same way, as generally they are not so fiscally minded, but non-county hospitals do.
I purport that all psychiatric illnesses should be seen in the same light as a “medical illnesses,” which cause one’s inability to care for oneself. Whether people are in danger because of dementia or paranoia, they are unable to care for themselves and equally in danger of harm and suffering.
Often it is very difficult to discern why someone is unable to care for themselves. I have a patient who I see weekly at the Center for Harm Reduction on skid row who is frequently hospitalized for severe paranoia, which causes her to threaten those around her. She also ends up getting beaten or raped often, putting herself in harm’s way. This generally happens when she is using methamphetamines.
I have another patient I was taking care of in the women’s jail who started to have delusions and paranoia in her 50s (usually psychiatric conditions don’t start that late in life). She improved on psychiatric medications, but with much investigation and laboratory testing, it was discovered that she had Lupus, which was causing her psychiatric symptoms.
It really shouldn’t matter. Whether due to dementia, lupus, drug use or schizophrenia, these people cannot take care of themselves, and it is up to us, their community, to take care of them—the Barbaras—as if they were our mom.
Susan Partovi, MD, is the medical director for Homeless Health Care Los Angeles and co-founder of L.A. County’s Grave Disability Work Group. She started working in 2003 with people experiencing homelessness at the Venice Family Clinic and in 2007 participated in creating the first Street Medicine Team in L.A. and continues to work with the most vulnerable people in LA— people experiencing homelessness, those who are severely mentally ill and drug users. She has since 2004 worked in LA’s skid row area, where she spearheaded street medicine, Narcan distribution, Medical Assisted Treatment for opioid addiction and Long Acting Injectables for those suffering from psychosis.
This essay is excerpted from Partovi’s upcoming memoir, “Renegade MD: Stories from the Streets of Los Angeles,” www.therenegademd.com.
Photo credit: Yandry_kw; Shutterstock