Countless Angelenos struggle every day with finding — and affording — the right mental health help.
Getting and maintaining that help can prove even more difficult if you live on the streets with a severe mental illness.
The latest homeless count from the Los Angeles Homeless Services Authority (LAHSA) found that 25% of unhoused people in L.A. County self-reported experiencing severe mental illness. That’s up from 24% from last year's count.
And research shows that in 2020 there were, at minimum, some 4,500 unhoused people in L.A. County who have been diagnosed with a psychotic spectrum disorder like schizophrenia.
It’s a staggering number of people living unsheltered with some of the most debilitating conditions.
And the people who treat and care for unhoused people in L.A. say they need more help.
On a recent busy Monday at the USC street medicine team home base in Alhambra, Brett Feldman loaded up bags with medical supplies, medications and all the equipment he needs to see about eight patients a day.
Feldman, director and co-founder of the Division of Street Medicine at USC and his team will treat wounds, check blood pressure and draw blood.
But he said there’s still more that could be done to help people living with mental illness.
“Psych time on the street is really rare,” Feldman said. “There’s just a national shortage of psychiatrists.”
In a recent report Feldman co-authored, he recommended that more frontline medical workers — like physician assistants — receive training on how to help treat behavioral health conditions.
“One of the things we’ve been trying to do statewide is encourage those doing primary care street medicine to really educate themselves ... to feel comfortable to do treatment for behavioral health at the top of their scope,” Feldman said.
Feldman and his team’s first stop is near a freeway onramp at Hollywood and Van Ness. The patients Feldman was hoping to find here have disappeared. A left behind cardboard sign reads: “Pregnant traveler in need of supplies. Everything helps.”
But Feldman and his team pressed on. They decide to visit a patient they’ve been following for some time now.
Ami Tallman and her dog Lobo live in a trailer parked in a backyard. She’s been a painter for 40 years. People tell her she’s a history painter.
“I’m very interested in history so I tend to paint historical events that I’m, sort of, obsessed with that day,” Tallman said.
Tallman showed a picture on her phone of one of her pieces, a painting of an apartment building in Ukraine. A bomb has ripped off one of the walls and the interior of peoples’ personal spaces are on full display.
Feldman first started treating Tallman back when she was living under a bridge near the 110 Freeway.
“Being homeless is a form of insanity,” Tallman said. “I know a lot of people, when they’re on the street for a while, people stop looking at you, they stop talking to you. At that point your own conversation becomes pretty attractive.”
As she had her blood drawn, Tallman offered what she believes could help people living on the streets with a mental illness.
“I mean, it seems like you could offer them a place that they could get treatment, that they could stay that wasn’t carceral or contingent on them following a specific course of treatment that’s against their will,” Tallman said.
Back in the truck, Feldman explained that people living on the streets with serious mental illness are the hardest to help get housing and treatment for, even if they want it.
And he says a lot of resources just go towards mental health emergencies, which he likens to treating people for a heart attack but not their hypertension.
“So there needs to be street medicine that follows them for mental health, longitudinally and then they’ll be more housing ready, they’ll be more able to organize themselves and follow through on appointment and paperwork and interact with people and be successful in housing,” Feldman said.
At the team’s next stop, a large park in the Los Feliz neighborhood, Tifani Caesar sits up against a large tree. A small sign that reads “Aloha” hangs from the trunk behind her.
Yelipsa Madera, a medical assistant, checks Caesar’s blood pressure and asked her some questions about her health.
Caesar said she struggled with postpartum depression after the birth of her son. When asked what she thinks would be most helpful for unhoused people living with mental illness, Caesar responded:
“A psychologist or somebody on staff for people to talk to. Somebody that’s always available. So if you have an issue, you can go and try and find some conflict resolution.”
Caesar said she believes there is a kind of tyranny coming from the neglect of people living with mental illness.
“The mentally unhealthy have been alienated. Instead of integrating them, you know, we just fringed them and short-bused them over there,” Caesar said.
Janey Rountree, executive director of the California Policy Lab at UCLA, worked on a study which found that roughly 4,500 people who were unsheltered and received street outreach services between 2019 and 2020 had been diagnosed with a psychotic spectrum disorder such as schizophrenia. That’s about 10% of the total 45,000 unsheltered people the study examined.
“It’s just an enormous number of individuals who are experiencing this and also who are unsheltered and living on the street ... That’s a larger population than most communities' entire homeless population,” Rountree said.
Rountree and her colleagues incorporated SMI diagnosis and treatment logged in county records in their research.
“To put that into context, there are clearly people who are on the street who are disconnected from services ... Those people are not going to be captured by our study,” Rountree told LAist.
But Rountree’s study also points out that “the vast majority (83%) of Street Outreach participants do not have a County service history with a diagnosis for any serious mental illness in the five years before enrolling in Street Outreach services.”
Rountree says while people living with SMI might be the most visible on our streets, the one thing all unhoused people have in common is severe poverty. And sometimes that gets lost when we try to blame homelessness on just mental illness and drug use disorders.
“And so in some ways I would urge our community — all of the people who work on this, elected and journalists and others — to shift the conversation away [from] who has the most accurate estimate towards: What are we going to do for the people that we know are experiencing this?” she said.
La Tina Jackson, deputy director of countywide engagement division at the L.A. County Department of Mental Health, heads up the Homeless Outreach and Mobile Engagement (HOME) program. The first of its kind in L.A. County, Jackson said the program started working with unhoused people living with a mental illness around 2020. They have eight total psychiatrists doing street care and hope to expand soon.
“Street psychiatry in L.A. County is a pretty burgeoning practice,” Jackson said. “To have psychiatrists that are specifically dedicated to serving people that are unsheltered with severe mental illness in L.A. County is new.
Jackson agreed with Feldman that physician assistants and other frontline medical workers can “absolutely be used in this work.”
But she says having more street teams trained up to address mental health conditions isn’t a fix-all.
“The most important piece to me is, we have to have the resources to place someone,” Jackson said.
Because of decades-old federal rules, disappearing supportive housing and insufficient government funding, those places to stay are hard to come by.
According to a report from the California Health Care Foundation, in California “the number of acute psychiatric beds per 100,000 people decreased about 30 percent from 1998 through 2017.”
For starters, Jackson said parity with other physical and developmental disabilities would be “wonderful.”
“The rate at which the state pays for someone with a developmental disability could be upwards of $10,000 for someone to stay in a board-and-care and get the support that they need. For someone who has a psychotic spectrum disorder, it is roughly $1100 a month for that person to access the same,” Jackson told LAist.
Jackson said she’s excited about bringing psychiatric care to unhoused people, but she gets nervous when politicians see street psychiatry as a panacea.
“If you don’t have the system around to place people, to get them care, it’s a moot point ... We’re providing medication on the street [and] that’s not appropriate either for a long term kind of strategy,” Jackson said.
On the way back to home base, Feldman explained that many of his patients won’t lead with their mental health condition.
“For example, today, one of the new patients, they came to see me because they had a rash. They also had uncontrolled bipolar disorder,” Feldman said.
Feldman said he and his team have worked hard to gain people’s trust. They never promise something they can’t deliver and they come back when they say they will.
It’s relationships like these that make patients more comfortable opening up about their mental health struggles as well, Feldman explained.
Feldman said he wants his team to be a “stalwart on the street,” building relationships with the community so that they know enough to send in more specialized mental health care when needed.
“We don’t want to be yet another person that’s abandoned them.”
