Originally published on January 28, 2023 in Los Angeles Daily News

By Clara Harter and Steve Scauzillo

Dr. Brian Benjamin, a psychiatrist specializing in serving the homeless, was excited to tell one of his regular clients that a shelter spot had opened up, but unfortunately there were 20 murders in that building every day and the Mafia lived there – or so the client told him.

The client, who Benjamin did not name to respect his privacy, suffered from hallucinations, delusions and paranoia as a result of schizophrenia.

“I do think there’s a lot of times where there’s a direct connection between their (homeless individuals’) mental illness and their inability or unwillingness to go into housing,” said Benjamin.

His client is not alone.

The Los Angeles Homeless Services Authority reported in 2020 that about 25 percent of all homeless adults in Los Angeles County suffer from severe mental illnesses such as a psychotic disorders and schizophrenia. A 2022 study by the RAND Institute found that 54% of unhoused Angelenos reported having a mental health condition.

And, when a broad view of mental health is taken into consideration – including depression, stress and anxiety – some experts argue that it impacts all homeless people.

“Being on the streets for any amount of time under stress creates mental unwellness,” said Zachary Coil, director of Westside outreach at The People Concern. “Everybody on the streets is struggling with mental health.”

So while the estimates vary the conclusion is clear: mental illness is a real and prevalent problem among L.A.’s unhoused.

Even when clients with severe mental illness get housing, challenges remain.

Benjamin said another of his clients was recently housed, but is now on the brink of being kicked out of his unit, because his mental illness led to him hoard trash and refuse to let anyone clean it up.

“There’s a lot of people on the street whose mental condition has kind of exacerbated their lack of housing stability,” said Steve Fiechter, senior director of clinical services at People Assisting the Homeless. “And symptoms such as paranoia might drive people out of permanent housing because they’re in a state of psychosis.”

Los Angeles’ politicians are currently laser-focused on the dire need for more permanent and temporary housing, while the pressing need for more mental health services draws comparatively less attention.

To make matters worse, experts say, even when funding is made available for homeless mental health professionals, organizations are often unable to find staff to file the roles.

A mental health ‘staffing crisis’
When asked what was the hardest part of her job, Laura Pancake, senior vice president of clinical operations in L.A. County for the community-based mental health nonprofit, Pacific Clinics, did not hesitate:

“Finding the workforce to do the work. When you don’t have enough people, it wears on your current employees,” said Pancake.

Pacific Clinics provides outreach teams who go into the streets to assess a homeless person’s mental well being, place them in care and also lead them into temporary and permanent housing and job training.

Pancake has been doing this work for 30 years. Since the COVID pandemic struck, finding social workers, therapists, and psychologists to join an outreach team has been extremely difficult.

“The idea of sitting at home and providing tele-mental health is tempting to people. Particularly during COVID,” she said.

The prospect of higher pay in private practice is also a deterrent.

“To do this work you would have to sacrifice some of your earning potential,” said Coil, at The People Concern.

COVID-19, which brought about isolation that lead to anxiety, depression and suicidal ideation, also exacerbated the physical and mental health needs of the housed and unhoused.

“There is a massive workforce shortage,” Pancake said. “There simply are not enough workers to provide mental health services in Los Angeles County. And the demand is at an all-time high.”

The county’s Department of Mental Health has 33 available outreach teams, about the same number of teams it had after it hired more workers, because as new staff came in others left, said Lisa Wong, interim director of DMH.

“The biggest challenge we have with staffing is hiring and retention of staff,” Wong told the Board of Supervisors in a briefing on Tuesday, Jan. 24.

Fourth District Supervisor and Board Chair Janice Hahn said that 35% of the time, after receiving calls for mental health services, getting someone to the scene took more than four hours.

The City of Santa Monica announced plans in May 2022 to launch a therapeutic transport van staffed with Department of Mental Health behavioral health professionals to respond to 911 calls. Nine months later the program is yet to roll out, precisely because the department has been unable to staff it, said Santa Monica spokesperson Constance Farrell.

Street psychiatry is a powerful solution
The staffing shortage is dangerous, because when trained behavioral health professionals are unable to respond during mental health crises bad things tend to happen.

Take for example, the case of Keenan Anderson, a man who went into cardiac arrest after being tasered by the LAPD. His crime, many have said, was having a mental health crisis and wandering in the middle of the street.

“Someone with a psychotic disorder going on can appear very frightening to people… and there are safety issues that can arise from erratic behavior, but people with mental illness are far more likely to be the victims of crime than the perpetrators,” said Fiechter. “Mental health professionals will be more able (than police) to recognize what’s going on and perhaps offer a more effective approach to engaging that person.”

LAPD does have a team of mental health professionals in its Mental Evaluation Unit, but due to overwhelming demand the unit has notoriously slow response times.

The shortage of street psychiatrists can also hold back the success of outreach teams in moving service-resistant individuals into shelter.

Dr. Benjamin, for example, has a tried and tested tool kit to help get his schizophrenic clients “housing ready.” It starts with his repeated visits to gain their trust and then, with his client’s consent, he administers an Invega Sustenna shot, which can provide a steady dose of anti-psychotic medication for up to a month. His hope is that over time clients will understand that their delusions are not real and will be open to moving indoors, he said.

“I think it’s been a fundamental game changer,” he said of the Invega Sustenna shots, noting that people with severe mental illness are often unable to show up to regular clinic visits or remember to take daily medication.

Mental health and substance use call for integrated care
Another challenge in treating mental illness among the homeless is that their symptoms often intersect with substance abuse issues.

Sarah Hunter, director of the RAND Center on Housing and Homelessness in Los Angeles, said assessing a person’s mental health on the street is tricky, because being high on methamphetamines could mimic a mental illness.

Because 50% of the homeless population in L.A. County have both substance abuse and mental health issues, they need to be treated for both. But because each area represents a separate silo of care, that rarely happens, Hunter said.

Brian McIlroy, 42, is a rare success story of where that did happen.

McIlroy said he was a crystal meth addict and on the brink of killing himself when a People Concern outreach team found him on a Santa Monica beach in October 2021.

“I was diagnosed with drug-induced psychosis, which brought me to severe depression, which was why I was trying to commit suicide,” he said.

The People Concern were able to place McIlroy in a detox program at Clare Matrix addiction treatment center, where he was provided with housing, substance use treatment and mental health support. Now he is living in an adult residential care facility in Santa Monica and, quite literally, has a new lease on life.

“I’m clean and sober these days and I’m getting my life back,” he said. “I got a new job and I’m saving my money and it’s all because of The People Concern.”

Dr. Coley King, director of homeless health care at Venice Family Clinic, said drugs such as methamphetamine can both cause mental health symptoms like psychosis and also worsen people’s pre-existing mental illnesses.

People often take drugs to cope with the physical pain and trauma of living on the streets, he said, but with time this can have wreak havoc on their physical health.

Trauma informed care is essential
Physical health and trauma are two additional factors that can impact the mental health outcomes for the homeless.

This was certainly the case for Sharon Gelfand, who experienced homelessness for the first time in her fifties after settling a divorce with an abusive husband.

Sharon had a troubled childhood and was a victim of sexual assault and a runaway teen. Later in life she developed multiple sclerosis, a debilitating autoimmune disorder that was worsened by her homelessness. The combination of stress and physical pain gave her depression, anxiety and insomnia, which made it difficult to work toward any housing goals.

Fortunately, through service providers St. Joseph’s Center and Venice Family Clinic, she got treatment for her physical and mental health and ultimately got a permanent housing placement.

“It’s no exaggeration to say they are lifesavers,” she said.

Gelfand now serves on the board of the Venice Family Clinic and recently completed a trip to Washington DC to speak with legislators about best practices in providing homeless services.

“I believe a highly significant portion of my patients have had early childhood trauma and that is one of the origins of someone with mental health difficulties,” said Dr. King.

Simply being on the streets is traumatizing in and of itself. “One night on the streets is scary — it changes your mental picture and your physiology and your emergency response,” said King. “You’re a different person.”

A high level of trauma is one of the reasons people are sometimes distrustful of offers of housing.

“The traumatized brain is working out of its brainstem, where it only has three choices: fight, flight or freeze, and we’re expecting people to make nuanced decisions about what part of town they want to live in,” said Fiechter. “Someone who understands mental illness a little bit better can engage that person on a level that they’re able to communicate with their brain.”

Under-resourced at every level
Street psychiatry, long-acting antipsychotic medication, integrated substance use care, trauma-informed outreach – these are all proven strategies that help homeless people with mental illnesses get back into housing. But there is not the staffing, or the funding, to serve the vast need in Los Angeles.

The lack of mental health infrastructure also plays a role.

According to a 2021 study by the RAND Corporation, the state of California requires approximately 50 inpatient mental health beds per 100,000 people. Los Angeles County has a shortage of 5.6 beds for short-term psychiatric holds per 100,000 people and a shortage of 11.6 beds in residential care facilities per 100,000 people.

“We remain thousands of mental health beds short of our current needs,” said Fifth District Supervisor Kathryn Barger in a Jan. 24 meeting.

Governor Gavin Newsom recently introduced CARE Court, a plan to use the court system to connect people who have schizophrenia or other psychotic disorders with treatment. His plan is in response to the state’s mental health crisis.

While many politicians have lauded the program, others worry that court-mandated treatment will infringe on people’s rights. On Jan. 26 a group of disability rights organizations filed their complaints about CARE Court to the California Supreme Court.

Some homeless services support Newsom’s program, but say it’s not nearly enough to address the overall crisis.

“I think, as a small part of this solution, it’s a good idea. I think that people have really put all their eggs in one basket with it,” said Coil.

CARE Court is designed to serve only an estimated 7,000 to 12,000 people statewide. Homeless service providers would also like to see greater investment in all types of mental health services.

“Those of us in the field will say over and over again, there are not enough resources, we need more and more,” said Fiechter. “It doesn’t mean that the approaches are ineffective, it means we don’t have enough of them.”