S1: Welcome in San Diego , it's Jade Hindman. On today's show , we are talking about the state of mental health care and how to overcome obstacles like access and even cultural stigmas. This is Midday Edition , connecting our communities through conversation. It's no secret California is dealing with a dual crisis of homelessness and mental health. A new book , sons , Daughters and Sidewalk Psychotics , looks into these crises by comparing two drastically different mental health programs in Los Angeles. It's a deep dive into how our current system fails poor and wealthy patients and everyone in between. Midday edition producer Andrew Brackin sat down with author and UCSD professor Neil Gong to talk more about the book and the state of mental health care in California today. Here's that conversation.
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S3: I thought I was going to be a therapist. And my first job after college was on a community mental health treatment team. And as I was doing this work , I just began to see all of these problems that a lot of us , I think are increasingly familiar with , which was patients who were cycling to the streets , becoming homeless patients who were going in and out of jail. And I just started seeing how broken our systems were. And so I ended up shifting from wanting to be a clinical psychologist and ended up going down the path to becoming a sociologist. I did a PhD in sociology at UCLA and went to go look at what public mental health care and homeless services were looking like there.
S2: And you , you focus on Los Angeles specifically here.
S3: So on the one hand , LA's famous for its downtown and for its Skid Row kind of America's homeless capital , where you have public and nonprofit providers , uh , serving a very disenfranchised population. And yet on the other side of town , you have West L.A. and Malibu , which is a treatment destination for privileged people not just from LA but from other areas who flock there for beachside treatment , different kinds of elite psychiatric and addiction services. So it's , you know , within one city , we can sort of see these two worlds of care.
S2: How did you really see inequality play out there ? Yeah.
S3: So as you could imagine , you know , clinics for the wealthy look very different than clinics for the poor. And they're focused on different things. So clinics for the poor are addressing these things like the criminalization crisis and the homelessness crisis. So a lot of it's this kind of guerilla social work , just whatever it takes to to help people get housed and stay housed , stay out of jail. And so that's kind of what the idea of success and recovery is. Whereas in these elite clinics , it would be things like , you know , getting an adult , someone's adult child back into college after a psychotic break , or finding hobbies or doing family therapy to address complex family dynamics. And so it's really it's kind of in some sense , apples and oranges , uh , what these clinics are up to. And this can lead to very different practices. So in the public clinics , if the goal is , you know , whatever it takes to keep people housed , they end up doing things like this kind of harm reduction model that says , we'll get you into housing and there's not a prerequisite of sobriety or medication compliance. And there's good evidence for why this is an important practice , but it ends up looking very different , right ? If you're looking at at elite care , where it wouldn't sort of make sense to to have an intervention around having people , in some cases psychotic and high in a subsidized unit , there's a whole different set of ideas around what treatment looks like , because you're aiming at these goals , like getting somebody back to college after a psychotic break , as I mentioned. And it can take a week to these kind of strange ironies. For instance , poor patients having more autonomy because they're there in this more harm reduction model , they're given more leeway with what they're with , are allowed to do , in part because nobody has some sort of advanced goal for them. On the other hand , for some of these more privileged people , it was very interesting to me. Sometimes people would be getting access to what I thought of as , you know , expensive elite care , but would feel much more micromanaged , in part because , you know , their , say , upper middle class family is trying to dictate certain forms of normal behavior , quote unquote , normal behavior.
S2: And you write about how , you know , these programs sort of emerged from this closure of asylums. Can you tell us more about that history and how that changed ? Sure.
S3: So for for quite some time , the approach to dealing with serious mental illness in the United States was to place people into long term psychiatric hospitalizations. So this could be the state mental hospitals that , you know , at one time in the United States housed about 600,000 people at its height in the 1950s. And there was both there was available kind of as a resource. So to speak. And also the laws were different , such that it was relatively easy for city officials or for families to have a person locked up , and sometimes for years at a time. Now , in many cases , these were horribly oppressive places with both abuses and neglect. But at the very least , what they did was they , um , put a roof over people's head and provided them with the basic necessities of of survival. And then in the between the 1950s and 80s , actually an extent over an extended period , uh , there were a lot of critiques of these abuses , of the neglect , also of the cost , the amount of money that was going into funding these kinds of state mental hospitals. And so we ended up with kind of a strange bedfellows coalition of , on the one hand , progressives and civil libertarians who wanted to ensure patients had rights and weren't just being locked away , sort of without due process. And on the other hand , fiscal conservatives who believed that the state hospitals were too expensive. And so these two things came together. And there was this belief that it would be a win win. You would have an increase in civil liberties and cost savings. And then , uh , over a period of time , we ended up , uh , releasing many people and eventually closing many of these state hospitals. And the idea was that they would be replaced by high quality , community based services and housing for people with serious psychiatric disabilities. But really what we did is we closed the with a kind of bad system and plan to fund this a good one in the community and never really did the second thing properly.
S2: In your book , you also write about this idea of tolerant containment. I mean , what's the what's the idea behind that ? Yeah.
S3: So tolerance containment is how I see the current approach. We have to serious mental illness and to some degree addiction as well. The idea is that we've taken a step , a good step in the direction away from things like , you know , simply hospitalizing people long term or mass incarceration or trying to respect people's rights. And so we're trying to be more tolerant of people who are who are exhibiting what might think of as strange behaviors or not simply jumping to incarcerating people for their drug use. But we also haven't actually created the kind of services such that we could truly address people's mental health needs or addiction. And so what we end up doing is trying to create spaces where we can contain seemingly problematic behaviors , and then we tolerate them. So so one instance of this would be something like supportive housing , what's known as the Housing First model. You get someone into an apartment and from there we're not we're not demanding that they be sober or complying with a doctor's orders in order to get that housing. The idea would be then , you know , the best case scenario , you would follow that up with lots of high quality care. Unfortunately , more often than not , we just do the first thing and put people in the housing so we contain them and then sort of tolerate sometimes self-destruction. A similar kind of thing can happen sometimes with with homelessness , where we have court cases that say , you can't , uh , sweep encampments if we haven't offered people adequate resources in terms of shelter and things. And so people have something of a right to , to , to be homeless there , but we actually don't provide the kind of housing so that they might have a right to housing. So instead what we do is we create certain parts of cities where , where we tolerate encampments.
S2: And we've seen that here in San Diego , which past its encampment banned last year and is required to provide shelter beds , you know , as part of that , but often struggles to do so.
S3: So housing , I will say that housing first done right , is a very important intervention and should be a cornerstone of of our approach to addressing especially chronic long term homelessness. So at its best , as I was mentioning , Housing First means getting people immediately into housing and then providing them with these kinds of intensive wraparound services to help them with whatever it is they need in the housing offers stability and safety , in which case people are often more able to work on some of their issues. The problem is , in many cases , Housing First ends up looking more like housing only , so those robust wraparound services never really manifest , in part because they're very expensive. So there's a lot of programs that call what they're doing housing first. But it's pretty different than the the robust version of Housing First that we see in a lot of studies that finds these good outcomes. So it can be done very well , but unfortunately in too many cases it's not done well. And then the other thing I'd say about housing first is research shows about an 86% housing retention rate. And this is even among people who have , uh , various kinds of , you know , co-occurring disabilities , uh , could be addiction and mental illness , maybe a physical disability as well. And so these are people who are considered harder to assist. And so that 86% retention rate is very good. But that still means that you have 14% of the people who are going through these programs who are not staying housed. And so even in our our more robust programs and tolerant programs , they don't seem to be working so well. Even if we do have well funded housing first , there will be some percentage of people who for whom it's not working , and we may need to look at other options , which sometimes might include things like psychiatric hospitalization.
S2: And you you actually write about one man , Jeremiah , who's seen as , you know , as a success under this model. Can you tell us about his story ? Yeah.
S3: So I met Jeremiah on the streets of LA with , uh , mental health and homeless outreach team. Uh , someone had called in. He was there with a towel wrapped around his head , drawing messages in the dirt. And he was identified as part of the target population. And they helped him get into housing. They helped him get access to treatment , and he was very grateful. He was also he was , uh , from Jamaica. They helped him iron out some issues he'd had with his immigration status because he hadn't been reporting. He'd been on the streets and in psychosis for some time. And so on the one hand , he was very grateful they helped him get access to housing , medication , help , as I mentioned , with his immigration. And they got him to this sort of bare level of stability. But then , you know , he told me , you know , but there should be more. Right ? And what he meant was that he was very grateful that they had helped get him off the street. But that was kind of where the program stopped because they had other fires to put out. They had other people who they were trying to help get off the street or get out of jail , uh , or get out of crisis. And so what he was hoping for were things like , um , you know , reconnecting with some of his family , with his estranged wife , perhaps getting computer training , other kinds of things that simply couldn't be prioritized in one of these public clinics because there was so much other chaos going on , which isn't to blame. The workers they themselves are , are dealing with an almost impossible task and did did well for him. But unfortunately , that's kind of of what's available.
S2: And with Jeremiah , you mentioned resources and the problems that understaffing can create , at least when it comes to mental health. You know , tell us more about how that comes about. Yes.
S3: Yes. So in many cases , uh , case managers are simply putting out fires. Um , this could be , you know , a crisis around , you know , perhaps someone is is being hospitalized , but it could also just be things like keeping the housing instability that so many patients are facing and not just patients. There's lots of people in California. Um , they're dealing with things like having to move people from one house to another. You know , this could end up sucking up a , you know , a case manager or a social worker half their day. Um , and this all just means that time that could be spent on things we might think of as being more explicitly therapeutic , whether that's running group therapy or individual therapy , uh , helping people with , you know , kind of more fine grained aspects of their life , all that goes out the window. And so for the most part , it just ends up being this kind of grill of social work , trying to , again , keep people from becoming homeless again or keep people from being arrested if they're if they're in a crisis. Uh , things of this nature.
S2: Last month , you wrote an op ed for the Los Angeles Times about proposition one , and that narrowly passed in March. It would create a $6.4 billion bond and reprioritize county funding to build more housing and treat those with serious mental illness and addiction. Talk more about that and your thoughts on where we're going.
S3: Sure thing. Yeah. So so a lot of the debate around prop one was around , you know , how much of this money was going to go towards involuntary treatment. And this is a very important debate always to be had around civil liberties and whether people have even been offered voluntary treatment before , you know , later down the line , they're being forced into things. What I wanted to focus on in that , in that op ed was getting away from the sort of yes no , which is a long standing debate , um , around things like expanding force treatment , you know , between civil libertarians and those who want more forced treatment. But I was really trying to emphasize in that op ed was that quality of care matters immensely , because we have research that shows with a lot of our current involuntary treatment. Um , you know , for proponents who think this is just going to magically fix things , it often backfires tremendously. So people report , uh , feeling traumatized when they're forced into care. We even have evidence of elevated suicide rates , uh , and then people disengaging from treatment afterwards because they feel violated. And so you can't simply say , oh , it's a question of let's , let's just have more beds. It's a question of doing it right.
S2: I think The New York Times noted this ideological shift towards involuntary treatment. We've seen it here in San Diego. Mayor Todd Gloria , it's been a leading voice in reforming Conservatorships , for example.
S3: One is I mean , truly , people are seeing a great deal of suffering on city streets. Um , you know , there's the crisis around patient homelessness and incarceration. So part of it is certainly , I think , motivated by by care and compassion. There's another element of it that is that it's political , um , that politicians feel that they need to appear to be doing something. And so they're actually , in many cases , uh , trying to or at least claiming to address a lot of very complex issues through the lens of mental health. So you'll hear people talk sometimes about like how whether it was prop one or expanding Conservatorships is going to address our broader problem of homelessness on city streets. I mean , it really can't , like with prop one , the amount of housing they were talking about expanding , you know , 4000 some odd units and then , uh , as well as for the treatment beds. But really it's it's not going to put a dent in our broader problems of homelessness , which are primarily about housing supply and housing affordability. And so I think there are those two components to it , to to a genuine concern with people's well-being , but also , um , the political dimension of it.
S2: You've said before , quote , one thing we really need to figure out how to do is to make the small amount of force treatment that we might need better.
S3: So as I mentioned before , we have all of this evidence that forced treatment can backfire tremendously. Um , and so what we need to do is be talking to people who have gone through it and figure out , you know , what were the specific things that went so wrong and then put them in positions to work to redesign the force treatment that we have. So you could imagine things like finding somebody who themself is an architect who has been through , uh , you know , a 5150 emergency hold. You could imagine them collaborating with other people who have been through , uh , psychiatric hospitalization , trying to work to design less , alienating psychiatric wards. We can imagine redesigning court procedures. So this could be a , you know , a conservatorships or around these newer things like care courts to ensure that there's what people call procedural justice. So even if a person ends up losing their case , they're treated with respect and their and their preferences are taken into account and they're truly listened to. So there's there are a number of ways that we can improve. Again , you know , our goal should be trying to minimize the amount of coercion. But in the case that it is needed , um , there's a tremendous amount of ways that we can we can make this better.
S2: So what can we change about the mental health care system ? You you know , you outlined some possible solutions here in the book. Yeah.
S3: Yeah. So so certainly , you know , one big part of it , um , is we need a huge influx of resources. Uh , both on the housing side , but then also in the care side. So , uh , a lot of our , our care practitioners can't actually , uh , do well by their patients if they're not fairly compensated and if they're expected to take on , uh , two big loads. So in some sense , you know , addressing our mental health crisis is also a labor issue. Um , working conditions are also the conditions under which people receive care. So certainly , um , improving resources also for those workers. But then alongside this , there has to be a shift in how we look at treatment in the public and nonprofit sector for poorer patients. Right now , as I've suggested , we look at success kind of just in terms of these metrics of keeping people off the street , uh , keeping them out of jail , uh , often oriented towards saving money. And these are reasonable things to start with , but we have to change our viewpoint and actually think in terms of people's dreams about helping them move beyond this. Otherwise we leave them stuck just at , uh , at this kind of baseline of survival.
S1: That was sociologist and UCSD professor Neil Gong. Talking with Midday Edition producer Andrew Bracken about his book sons , Daughters , and Sidewalk Psychotics Mental Illness and Homelessness in Los Angeles. That's our show for today. I'm your host , Jade Hindman. Thanks for tuning in to Midday Edition. Be sure to have a great day on purpose , everyone.
