LA officials struggle with options for homeless with mental illnesses

Officials in Los Angeles County are looking for ways to get homeless people into treatment for mental health and substance abuse issues, but options for those who refuse help are sticky.

"Really, at the end of the day, there's a tough balance here between autonomy and paternalism," said Dr. Jonathan Sherin, L.A. County's director of mental health, at the L.A. County Board of Supervisors meeting Tuesday. 

Discomfort with how to find that balance has largely kept L.A. County from pursuing ways to expand options for forcing homeless people who might benefit from treatment into treatment. And that hesitancy continued Tuesday as supervisors considered recommendations Sherin offered on expanding the reach of the mental health department.

Supervisor Kathryn Barger, who authored the motion requesting the report back in April, said her primary goal is to move away from what's now a revolving door between the hospitals and the street. Homeless individuals who are in crisis are often put on temporary, 72-hour holds, given medication, and then released back to the streets.

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The L.A. Homeless Services Authority estimates that about 30 percent of the homeless population has a substance abuse problem, mental health issue, or both. 

"Hospitalization is a temporary, stabilizing factor, but the goal is to get them into a stable lifestyle," Barger said. "The question is how do you bring them into the system and get them the care they need?"

Various options exist, but access to them can be difficult. Those who are "gravely disabled" can be put, by a court, into a conservatorship, meaning decisions about treatment are made on their behalf by a relative or other third party. Other options, like group homes and out-patient treatment, depend on willingness of the patient, and availability and access to services. 

Sherin's recommendations included beefing up psychiatric mobile response teams, which are called  to assess people who are in crisis and determine whether to hold a person in a hospital for 72 hours. Per the recommendations, such teams would also have lighter options at their disposal, like transporting a person to a shelter or other type of treatment facility.

Sherin also recommended increasing the number of mental health beds in the county, to accommodate people who have been deemed gravely disabled by a mental illness in less hospital-like settings. And he suggested looking at filing more petitions for forced medication with the courts. 

Supervisors unanimously voted to pursue the suggestions, except for one — an expanded definition of "gravely disabled" to include those with medical issues who don't pursue treatment "due to a mental disorder."

"We feel it may be a way to engage those individuals who are languishing and suffering due to a mental illness when they might not be in such dire straights and are able to get into treatment," Sherin said.

Such a change would require new state regulations or legislation.

"I do worry always about those populations and how they're defined," said Supervisor Sheila Kuehl. "The LGBTQ community for instance, large number of our young people were institutionalized because they were defined as having a mental health issue."

Kuehl has consistently expressed concern over expanding the definition of "gravely disabled." 

Tuesday, she used the example of a cancer patient who refuses chemotherapy. 

"My family might think I had a mental disability in not wanting to take care of myself," Kuehl said. "So I want to make sure we know where we're drawing the line."

Supervisors agreed to table the idea of an expanded definition, at least for the moment