Wilkes, an outreach specialist for homeless people in Westwood, is tasked with an impossible job: provide care to those who refuse it. Every day, he asks his regulars with serious health concerns if they are ready to accept resources, such as housing or medical treatment. Every day, they reject his offers of help.
Often, the people he meets with are cognizant enough to refuse services, but their mental illnesses can deter them from seeking treatment, even if their health has deteriorated into severe, and sometimes life-threatening, conditions.
The death rate among homeless people in Los Angeles has increased nearly 81 percent in the last four years. A 2018 report from the Los Angeles County Department of Mental Health suggested a significant number of these deaths were caused by treatable diseases such as pneumonia and bacterial infection, often in individuals with mental illness.
Desperate to keep his clients alive, Wilkes has started considering the idea of involuntary commitment, a thought that makes him deeply uncomfortable. To him, involuntary commitment pits two fundamental ideas against one another: the belief in individual choice and the moral duty to help those who are unable to help themselves.
In the last year, some Los Angeles politicians have proposed legislation that would make it easier to involuntarily treat people living with mental illness. But doctors, politicians and Los Angeles residents disagree about the morality, and sometimes practicality, of increased institutionalization.
Wilkes sprinted down Westwood Boulevard to Yogurtland, where Miss Mary slept every night. A Yogurtland employee was in front of the store, already setting up chairs and tables for the day. Miss Mary was slumped facedown over the brick stoop in front of the store.
Wilkes called her name. No response. He gently shook her. She jolted awake and grimaced at him.
Miss Mary’s health had been declining for a couple of months, but now Wilkes said it was worse. Her legs were badly swollen and she couldn’t stand up on her own. Seven minutes later, paramedics arrived.
They asked her if she wanted to be taken to the hospital.
Miss Mary politely declined.
They asked how she was going to walk.
“I’m fine,” she said.
Under the current law, as long as Miss Mary denies services, Wilkes can’t do anything to help her.
“Her whole arm could be missing and as long as she says, ‘I’m OK,’ that’s it,” he said.
Mark Morocco, an emergency medicine doctor at Ronald Reagan UCLA Medical Center, said some mental illnesses manifest themselves in the exact kind of behavior that makes it difficult for individuals to receive medical care.
“If you’re paranoid about your medications and you think they’re poison, because of the nature of your psychiatric disease, it’s pretty likely you’ll stop taking your medications,” Morocco said.
On his daily 6:30 a.m. walk through Westwood, Wilkes can describe each homeless person’s health conditions.
Julie, who sleeps in front of Stan’s Corner Doughnut Shop, has a tumor on the back of her head. Mike, who sleeps in front of Target, can’t go to the bathroom without stabilizing himself with a shopping cart.
Wilkes worries about Miss Mary the most, though. She’s the oldest. He said he thinks she is at the highest risk of dying on the street. Still, he struggles to get her to accept even trivial resources, like a toothbrush.
Melissa Montes, a city employee who has been checking on Miss Mary for the past five years, said Miss Mary used to wake up, take the bus down to Santa Monica to shower and eat, panhandle in front of CVS and then return to Yogurtland around midnight.
Now, it takes her two or three hours just to leave the stoop in front of Yogurtland.
“I always tell (Wilkes) I’m scared there’s one day where she’s not going to move and we’re not going to know what to do,” Montes said.
Others on the street have started worrying about Miss Mary’s health as well. Many give her old blankets and pillows, which she always declines.
Debbie, a homeless person who has known Miss Mary for four years, checks on her every day when she gets off of the bus.
“I say, ‘You need to get to the doctor – you could die,’” Debbie said. “She says, ‘No, I’m OK.’ She’s a good lady, she doesn’t bother anybody. But she needs to get off them legs.”
In a thick, green binder, Wilkes keeps meticulous documentation of all of his clients’ progress in getting resources. “Declined services” is scribbled next to each entry on Miss Mary’s record sheet. Wilkes submitted these records to the Department of Mental Health – to see if she would qualify for involuntary commitment – a couple of weeks after he called the ambulance for her.
Under the Lanterman-Petris-Short Act, state officials can detain someone if they determine they are gravely disabled – defined as unable to provide food, water or shelter for themselves due to mental illness.
People labeled as gravely disabled can be detained for 72 hours, at which point the court can order a 14-day hold for more intensive treatment or appoint a conservator, who takes control over their medical decisions.
The LPS Act, signed by then-Governor Ronald Reagan in 1967, attempted to end “inappropriate, indefinite, and involuntary commitment of persons with mental health disorders” by placing regulations on the way state officials institutionalize people.
It was the first law in the United States to aggressively attempt to deinstitutionalize patients with mental illness and did so with remarkable success, emptying 95 percent of the state’s mental health institutions.
But some politicians think California laws have swung too far to one extreme, celebrating independent choice while allowing patients with mental illness to die on the streets from preventable diseases.
The Los Angeles County Board of Supervisors approved a motion in January that asked California legislators to expand the definition of “gravely disabled” in the LPS Act to include those who cannot seek medical care for themselves.
For some, the motion was a blatant and unsettling infringement on freedom of choice. Supervisor Sheila Kuehl, the board’s lone dissenter on the motion, said medical institutions in California have historically stripped patients with mental illness of their right to make decisions for themselves.
“I worry about these decisions and what’s going to happen to people when you say, ‘You’re not taking care of yourself, I’m going to take care of you,’” she said during the meeting.
Others, like Susan Partovi, a family medicine doctor at UCLA, said they don’t think the bill is a violation of independent choice because they think without mental illness, many people would choose treatment for themselves.
Partovi has treated homeless people with mental illness for more than 15 years. Early in her career, her mentor told her about a homeless woman living on the streets of Los Angeles with paranoid schizophrenia. It took outreach specialists years to convince her to just accept a sandwich. Eventually, as her mental illness progressed, she was involuntarily hospitalized and treated. Years later, the woman ran into the outreachers and she was furious they didn’t institutionalize her earlier.
“She was basically like, ‘Fuck you for leaving me on the streets like that. How dare you not help me in my time of need,’” Partovi said.
After getting to know a homeless person, Partovi said she can often predict when they’re going to die from a preventable illness – whether it be in a couple days, weeks or months – but can do little to stop it from happening.
“You know that they’re going to die so you’re trying everything,” she said. “You’re like, ‘How about if I buy you a hamburger’ or ‘How about if I buy you some cigarettes?’ You’re following that whatever-it-takes philosophy to get them treatment.”
However, she said when these tactics inevitably fail, she thinks it is up to doctors and officials to make the final life-or-death decision.
“A child can kick and scream and say, ‘No, I don’t want chemotherapy,’ but if you’re a parent, you’re going to go ahead with the treatment anyway,” she said.
Partovi said passing a law that would provide care for medically and mentally ill people on the streets is the least California can do to handle the rising death rate of homeless people.
Sarah Dusseault, the former chief of staff for city Councilmember David Ryu, doesn’t think expanding the definition of “gravely disabled” is the difficult ethical problem that many politicians claim it to be.
“People are having these discussions without actually having the real life experience,” she said.
Dusseault said, for the last 20 years, she has taken care of her brother John Dusseault, who has come close to dying multiple times. She said many of the politicians arguing over the expansion of the definition of “gravely disabled” haven’t experienced the emotionally and financially exhausting process of helping a mentally ill family member get treatment.
John Dusseault was 20 years old and studying at Oklahoma State University when he first started showing symptoms of schizophrenia. His sister said he was charming, a talented pianist and looked remarkably like Bradley Cooper in “A Star is Born.”
As his mental illness became more severe, John Dusseault stopped going to class and spent most of his time in his dorm. A couple of months later, he dropped out of college. He cycled on and off of his medication and was on and off of the streets for the next 20 years. Sarah Dusseault would sometimes go months without knowing where he was.
When her brother was missing, Sarah Dusseault went through her usual routine: She sent pictures of him to local outreach agencies, regularly checked the California inmate tracker and filed missing persons reports to the police. She estimated she and her siblings filed at least 10 of these reports.
“The first thing they do is check the morgue for you,” she said. “My brother is in the range of people that are so severely ill that it is a likely outcome that he will die on the streets.”
Sarah Dusseault said she and her siblings have paid for their brother’s visits to the doctor, rent, furniture and clothing, among other things. The family has spent tens of thousands of dollars in legal fees alone, she said.
“They’re exhausted,” she said. “Everybody has jobs and families. It’s really hard to balance when you get a call out of the blue and you’re headed to a parent-teacher conference, and he’s only going to be on that street corner for 30 minutes.”
Aside from ethical concerns from family members and politicians, there are also practical concerns that might make this bill an imperfect solution. Many doctors are concerned about how an already strained mental health system would handle an influx of patients, committed under a new definition of “gravely disabled.”
Ariel Seroussi, an inpatient psychiatrist at the Stewart and Linda Resnick Neuropsychiatric Hospital at UCLA, said California already has a shortage of beds in psychiatric facilities. He worries expanding the definition of “gravely disabled” could exhaust the amount of space and staff available at psychiatric hospitals.
When beds are limited, patients are placed in a temporary-care facility while they wait for a spot to open in a psychiatric hospital. One of these places is the emergency room, which, according to Morocco, is just about the worst place to treat someone living with mental illness.
Morocco described the emergency room as a “public, blunt instrument” that can do little to shield patients from seeing gruesome injuries and crying family members. To anyone, this environment would be stressful. To patients with mental illness, it can be traumatic.
“(The emergency room) is never going to be the warmest and most human place for treatment,” he said. “This would be a terrible place to do any kind of basic communication-based treatment for people having behavioral health issues.”
Seroussi said he understands the rationale behind the bill and thinks it’s important to eventually expand the definition of “gravely disabled” if the state allocated more resources to mental health facilities. However, without additional staff, space and funding, he isn’t sure the mental health care system can currently keep up.
The California State Assembly passed the bill to expand the definition of “gravely disabled” in May, with little opposition. Then, a couple of months later in the state Senate, a familiar conflict arose: One set of legislators argued it is inhumane to involuntarily treat people, and the other argued it is inhumane not to.
State Sen. Holly Mitchell, who worked on the original LPS Act, compared California’s policy on institutionalization to a pendulum, oscillating between laws that place more value on the right to choose and the right to live.
“I don’t want the pendulum to swing in the other direction and start to peel back independent rights,” she said.
Amid practical concerns about funding and implementation, Miguel Santiago, the assembly member for District 53 and author of the bill, withdrew it before the Senate could vote.
The first time I met Miss Mary, she was folding newspapers and blankets into her black shopping cart in front of Yogurtland. She wore black track pants with white and blue stripes down the side, a black, cotton sweatshirt and a gray raincoat with the hood up.
She asked if I could walk to Starbucks and buy her her usual: a small, dark coffee with half-and-half, one pack of Sweet’N Low and whipped cream on the bottom. She couldn’t walk to get it on her own.
“Are your legs doing okay?” I asked.
She looked down and shook her head, “No.”
Wilkes said he doesn’t think Miss Mary wants to die on the street. He said she has moments of clarity in which she talks about how much she loves cooking. She closes her eyes and sways her head from side to side as she hums Frank Sinatra’s “Luck be a Lady.” Sometimes, she talks about going home to be with her children.
“If she wanted to die, she could have died by now,” Wilkes said. “She still eats, she still panhandles. If it was just that she slept there all day – that’s one thing, but she makes me think she’s still trying to survive.”
“I just don’t think she’s capable of knowing what’s best for her at this point.”