‘The vast majority have serious mental illness and drug addiction, which means they are not going to magically walk in to housing and have their problems disappear.’ ~ Dr. Drew Pinsky
Dr. Drew Pinsky, a board-certified physician and addiction medicine specialist who spent most of his career working in a psychiatric hospital, says he wakes up every day upset about the homeless crisis. “I’ve done this work for thirty years and I never thought I would see my patients dying in the streets. I am morally uncomfortable that I live in a state where this is allowed to go on.”
Pinsky, who is best known for his radio show “Loveline,” has quickly become an advocate for solving what he calls a drug addiction and mental health crisis, not a housing crisis. “When clinicians, politicians and scientists develop a position that becomes more theological than scientific, it’s always a disaster.”
He recently gave a talk at The White House and at The State of Downtown in Sacramento. The first thing he said when he came on stage in Sacramento, where one person dies on the street every two days, after spending time with law enforcement and the transient population, is that he saw signs of Tuberculosis on the streets and heard the same thing over and over: ninety percent of the homeless population are meth addicts. He praised the Sacramento Police Department and said they should receive medals for their work.
In both his recent addresses, Pinsky laid out how as a country we came to have so many people with mental illness on the streets. He explains from the book, American Psychosis, how psychiatrist Dr. Robert Felix, who had spent one summer working in a state mental hospital, influenced President Kennedy to close all state mental hospitals in favor of community health centers. This continued on through several administrations and by the time Ronald Reagan became Governor of California, half the state hospitals had been closed. Due to the total failure of the community centers, which were designed to prevent mental health “problems” with no directive on treating psychiatric disorders, Reagan had them closed.
Pinsky, who believes the majority of schizophrenics are now on the street says, “Because there was no provisions or plan in place, patients were pouring out of the hospitals by the hundreds of thousands and were going to the nursing homes, prisons and the streets to die.”
One of the many things Pinsky talks about are the “resistant cases,” the transients who refuse services, shelter and treatment. He believes these cases represent about sixty to eighty-five percent of the homeless population, and one of the biggest reasons for this is anosognosia, a condition in which the person is unaware of having a disability. This deficit in self-awareness, which blocks the brain to a person’s insight, affects patients with dementia, stroke, psychiatric illnesses and drug addiction.
“In a right hemisphere stroke one side of the body goes out and the patient doesn’t know it, even when they see their hand flop over,” Pinsky explains. “It’s the same condition in dementia, and if you left that patient on the street, you would be considered cruel and you would be liable. Yet the same symptoms present in psychiatric patients and drug addicts, but you can’t touch them. We privilege the very same symptoms in the law with psychiatric cases. This is a reaction to the excesses of psychiatry back in the 1950s and 1960s. I do not defend any of that, but the laws created more than a half a century ago in response, are woefully outdated and are not suited to the modern era of brain science.”
‘Nothing is lower functioning than not being able to house yourself, yet no one is or has triaged people on the street.’ ~Dr. Drew Pinsky
“We cannot change much in a dementia patient, but with a schizophrenic, if we don’t intervene, we are condemning them to future deterioration with a treatable disease whose course can be changed dramatically with early intervention,” Pinsky said. “Left alone to progress, a person is often destroyed forever. Treated early, they can potentially lead relatively normal lives.”
“Nothing is lower functioning than not being able to house yourself, yet no one is or has triaged people on the street.” Pinsky goes on to explain that when Los Angeles County, where three people are dying a day from homelessness, went out to transient camps with showers, it took an average of fourteen contacts per person to get them to agree to take one.
Regarding addiction, Pinsky says, “Drug addicts are the population we’re going to have the most trouble getting off the street. Drugs cause a disorder of priorities by washing aside all other priorities including family, work and survival in order to use. And no one advocates for drug addicts, even though most severe addiction is incited by childhood trauma.”
“The drive to use heroin is profound, and meth dismantles thinking. When the two are combined, it’s a horrid combination which is almost untreatable,” says Pinsky. “Amphetamine psychosis creates paranoid thought disturbances and bizarre delusions focused primarily on nearby relationships, such as the belief grandma is building a machine to torment them and the neighbors are in on it, or the government is putting thoughts in my head. A patient once told me being on meth is like having a strobe light going on and off and nothing is connecting.”
Because of these resistant cases in people with mental illness and drug addiction, Pinsky believes current laws must be revised and new ones put forward. “They will not go in to or stay in housing unless we have some means to motivate them.”
Modify Proposition 47
In 2014, California voters passed Proposition 47, “The Safe Neighborhood and Schools Act,” which made both serial theft of less than $950 per location and drug possession, misdemeanors instead of felonies. This has tied the hands of law enforcement, who can only “cite and release” when seeing open drug use and theft, and also eliminated the drug court’s ability to offer court-mandated rehab versus jail time.
“Addiction takes over all motivational priorities of the brain, and there are usually only three things that motivate drug addicts to get better: losing their child, their life or their freedom,” Pinsky says. “If my patients know they can get easy access to unrestrained drugs, they’re coming to California, where drug use is a misdemeanor, without consequences or the ability to get the patient in front of the court. They belong in mandated care, and in order to get sobriety it has to be your life’s work. You will get help, follow directions, go to meetings, get a sponsor, go to cognitive behavioral therapy and vocational rehab. And I’m in favor of medicated assisted treatment and harm avoidance; only ten percent of people with addiction in this country get treatment. I don’t think we’re going to get sobriety out of everyone.”
Revise the LPS Act with SB 640
In 1967, California passed the Lanterman-Petris-Short Act. The intention of this bill, which was co-authored by State Assemblyman Frank Lanterman and State Senators Nicholas C. Petris and Alan Short, was to “end the inappropriate, indefinite and involuntary commitment of persons with mental health disorders.” But it missed the mark by putting severely mentally ill people on the streets and in our prisons because the people who often care for them most—their families—lost all tools to give their loved ones the care they needed, at times, involuntarily.
Pinsky says, “The LPS Act maintains the silent genocide on our streets, because if you say I’m going to kill myself or somebody else, and you end up in the emergency room, but then a few hours later say ‘I’ve thought better of it,’ you’re released as long as you can answer the questions, ‘do you know how to get food and do you have shelter?’ Even if that means McDonald’s across the street and a tent on the sidewalk. No treatment and no assessment. You can just go.”
Senator John Moorlach, the author of Senate Bill 640, summarized on his website how the bill would remedy the issues of the LPS Act. “SB 640 would clarify the definition of ‘gravely disabled’ to align it with the original intent of the LPS Act. If an individual, as a result of a mental health disorder, is incapable of making informed decisions about their own personal wellbeing, there should be better metrics to help those who are simply incapable of helping themselves. This is especially important when the absence of significant supervision and assistance puts the individual at risk of substantial bodily harm. This failure has converted our jails and prisons into makeshift mental institutions and left a high number of seriously mentally ill homeless individuals with no means of treatment or care.”
Twice Moorlach, along with families of mentally ill individuals, presented SB 640 to the legislature, which fell on deaf ears. Pinsky added, “These families are left desperate, begging for help to get their homeless loved one off the street so they can take care of them and prevent them from dying, and the legislature was completely uninterested. Not passing SB 640 is indefensible and moreover it’s morally reprehensible.”
Remove the IMD Exclusion
According to the book ‘American Psychosis,’ in 1965 both Medicare and Medicaid “sought to exclude the mentally ill to avoid having the federal government usurp state fiscal responsibility. For Medicaid this was done by decreeing that Medicaid funds could not be used for individuals in mental institutions, which became known as the Institutions for Mental Diseases (IMD) exclusion.”
Pinsky believes by removing that exclusion and allowing Medicaid funds to pay for care in psychiatric facilities, this will have a huge impact on decreasing the number of mentally ill people on the streets.
Implement Psychiatric Case Advance Directives
Pinsky has proposed having a POLST (Physician Orders for Life-Sustaining Treatment) form for treating psychiatric disorders. “You fill out this form if your brain doesn’t work when you get medically ill, but we don’t do it for psychiatric illness where your brain is potentially equally dysfunctional. We need an advanced directive for psychiatric care which specifies what you want the doctor to do when your psychiatric illness decompensates.”
Build Environments of Care
“Four walls is not a treatment for psychiatric illnesses,” Pinsky says. “Any legitimate environment of care always includes the necessary services to manage psychiatric patients. Wrap around services are synonymous with comprehensive psychiatric services, which people don’t seem to understand. They include a psychiatrist, a psychologist, a medical doctor, a social worker, a drug counselor, a vocational rehab therapist and an occupational therapist.”
“There are dedicated services and beds for the homeless left unused and there is plenty of money to provide these services,” Pinsky explains. “If we start actually treating all the psychiatric illnesses in the street, we will quickly need to develop more environments of care like the Trieste Model or Haven for Hope, which are proven models that succeed.”
Pinsky regularly asks in interviews or on one of his many podcasts, “What does the body count need to be before we give up crazy ideas like building four walls will treat mental illness? This is the current policy we are pursuing in California: if we just have housing it will end. The vast majority have serious mental illness and drug addiction, which means they are not going to magically walk in to housing and have their problems disappear. If you’re not motivating people to get better, you’re condemning them to die. You’re committing manslaughter for the status quo.”
View Comments (51)
What a great article hits the nail on the head
This is a thoughtful article and will hopefully be viewed as the beginning of an important dialogue. While It is understandable that California residents are weary of homelessness, I do not support the view that a solution lies in the direction of restricting the hard earned rights and legal protections of homeless people, many of whom are disabled. In my research I've found much to criticize regarding homeless housing authorities. In my op
opinion we need to stop blaming the victims of an archaic, failing system and focus on changing the homeless services system. We are using shelter models that are iver a century old. We need to accommodate advances in the understanding and treatment of those disorders seen among the homeless population. For examole, while motivation is important, i do not believe that we can legislate motivation. There are far more humane ways to motivate people.
Great must-read article
Drew Pinsky is as qualified to speak on this issue as Kim Kardashian is on gene splicing.
Why is that? I'm curious to know your reasoning, given his background. Who would be better qualified, and where do you feel the answer to this complex issue resides?
Frank, it is so easy to snipe... what are your credentials? More importantly your contribution to this dialog and much needed focus leading to a true resolution? I hope you respond so clarity may be brought to your comment.
I also am a physician watching our society decompensate because we have decided that homelessness is caused by higher home prices etc. It's just not the case. Yes there are always that small minority of people who are homeless because of true job related issues etc. But the vast majority of homeless persons are mentally ill or addicted to drugs so severely they can not take care of themselves. We do them an injustice by saying the best form of help is to simply give them free housing. It will fail, absolutely.
And if they don't begin homelessness as resistant mentally challenged and drug addicted, they will get there. Just trying to adapt to the homelessness and stigma pervasive with being homeless. And some degree of "mental illness" , lack or loss of self worth, to end up without support to be in housing.
He has been TREATING these people, you imbecile. No one is more qualified.
Yes please elaborate. he is more qualified than most given his history..
I am so happy to see this coverage! Thanks so much Ramona Russell.
Brings it together Ramona-you are a fighter and will never stop doing what you do best-keep it up.
Very important article --- has specific information regarding what can be done to help the majority of those on the street --- for their sake and ours. Take the time to read it. If someone says, "yes, it's terrible, but what are we supposed to do?" you can tell them. The more people know about this, the more we can overcome the ineffective policy now in place and make this happen.
It's great to see someone who has finally proposed a real solution to this problem that appears to tie all the loose ends together into one comprehensive proposal. Now, let's get it implemented before it's too late!
I have lived in Sacramento since 1980. I have taken light rail to work since 2000 and ride the bike trail 5 times a week (since 1988). Needless to say I've seen the homeless problem up close and in some instances more personal than I wanted it to be. I would add to the Modify Proposition 47...and that would be that the Supreme Court is upholding the lower ruling on the homeless camping ban which takes tools away from local government to be able to deal with the homelessness. Parks Rangers on the bike trail have done a good job dealing with the homelessness problem even in light of this. Sorry but camp where you want/when you want/how you want/the world is my trash can and you'll clean up after me (right?) is not a good policy. This aligns somewhat (same logic) with Revising the LPS Act with SB 640, it provides a tool that is needed to help fix the problem as is the Remove the IMD Exclusion.
Some of the more in the weeds issue I have not really seen addressed are as follows.
Who will triage the homeless and who (local, state, federal organization where's that funding from again, who pays for this?) keeps that data (what gets included in that data, it personal that's for sure) updated as they are a mobile demographic. Are you going to chip these people to keep track of them (on Google maps), YIKES!! Once you do start processing (I know that is cold) these people (are you going to force them to the facility, remember the anosognosia (my mom had dementia, I know the drill), there is nothing wrong with me, now bug off, leave me alone, I know my rights, I just want to do my drugs!) how will this all go down?
Think of the population (that we are going to figure out what it really is, not just the one night in February counting people in shelters that they do now, what a joke!) that we have now in Sacramento, you need a big (warehouse) facility to keep people off the street and more importantly away from drugs (a lot of detox going here). Sound like a prison well, ya, if keeping you from doing what you want to do is prison, then sure it's prison in a sense, sad but true. If you get to the point that people are dried out (poor term but you get the point) now you have to figure out where they are at on the spectrum and that would be the work of the aforementioned "psychiatrist, a psychologist, a medical doctor, a social worker, a drug counselor, a vocational rehab therapist and an occupational therapist". Again, who pays for this?
One last comment before I get off my soapbox and that is the families of these homeless people. I am not always sure that all families are "begging for help to get their homeless loved one off the street so they can take care of them and prevent them from dying", as cold as this sounds probably some of the homeless were put out in the cold because they were too much to deal with or the families themselves are homeless (do we allow the homeless pregnant person to come to term?) or some people just are going to go over the edge no matter what you do to help (or what you think is help, they may not view it that way). This latter was the case with my sister who was a casualty of the opioid wars of 2017, legal in this case but once again the medical profession (shame on you, sorry Dr. Pinsky but the medical profession has its issues) put the gun in her hand, so to speak, but that is a story for another day.
I understand what you have said and agree with you on most. As a homeless woman that has been noted as mentally ill by my family ( whom I haven't gotten along with since they blame me for my father having a heart attack) but not by my therapist of 5 yrs. I am not an addict but a person that has been dealt some really bad hands, where do you draw the line? Everyone wants to put all the homeless in the same category, which is as fair as saying all Muslim's are terrorists. I worked, paid taxes, went to college, and raised 4 children on my own, without help from welfare or child support. I did it but one child gets sick and your in children's hospital for four years. Lost my job and my home I was buying, left state and sperated my family . Lost everything but I have my child. At the same time,my older daughter was kidnapped and was gone for four days. After the Amber alert I heard from a man. He helped me get her back. I also lost my best friend ????. Then my mind took a break. I'm so blessed that I came back and I've been doing great. I dealt with a lot the 8 yrs since I snapped out of my breakdown and I was in a collision with an Amtrak and broke my neck. Now 50 yrs old and I can't get anyone to hire me. I never thought I could go through anymore but then I lost my apartment. I'm homeless,on SSI and I have two small dogs that I love,who do you think will rent to me? You never know what puts someone on the street so we all need to be judged separately. Voting on something that puts us all in the same pile.
I have had family members who had a combination of Schizophrenia and Bi Polar. They would leave the house and give away clothes etc etc from a lovely home. It was caused by a family member who hung himself. Finally we found the correct drug and the person was able to live a normal life. Many can be helped. With Mental issues they will not stay in any kind of housing without help as they go into a blank state and cannot help themselves if they do not get mental help
Excellent article! As a First-Responder we see this population multiple times each day. It is not a housing problem, it is a mental health/addiction problem. Finally, someone sees what we see. Thank You.
It seems family members can't help these members of the family that are mentally ill or who have drug problems. Family members are not trained to do the job. It seems that if we had places like prisons do to put these that need help together and feed, treat and house them with nurses, doctors and trained personal, this could help. These people need to get off the streets, for their sake and health and that of others. Parents and schools need to have a workable plan to teach our young people how to avoid and control additive traits. I do admit I do not know all about what is available and what all the answers are!! I am just a concerned person who is wondering about my safety, that of others, and of course care that is need for those living in the streets.