Breaking the Cycle: How Policy Change Could Reduce Prevalence of Homelessness

By Brianna Oubre

An abandoned building that used to be Charity Hospital

On February 11, 2021, Shante Wade had a mental episode shooting two people in the emergency room of University medical center. Her family had noticed a change in her behavior weeks prior to this incident and attempted to get treatment for her but were turned down by those facilities because they did not accept Medicaid. Following this incident, the woman spent only two days at the psychiatric ward before being sent to jail. Wade is not the only one with this kind of story. Many people with severe mental illness in New Orleans end up in jail, where the behavioral healthcare has remained subpar, rather than in a treatment facility that is properly equipped to handle the mentally ill.

Many behavioral health advocates and pieces of local journalism have suggested that the treatment of mental illness in the criminal justice system of New Orleans needs improvement, but the story of Colby Crawford demonstrates how dire the need is to reform our behavioral healthcare system. The 23-year-old man had been diagnosed with schizophrenia, bipolar disorder, and substance use disorder. After being arrested for hitting his mom and sister, he spent about two months in a state prison before being transferred to Orleans Justice Center (OJC) where he died of an overdose.

Upon Crawford’s arrival at OJC, he spent 20 days in disciplinary segregation. Following his release from this disciplinary action, Crawford stopped taking his medicine and experienced a decline in his mental state. “He stopped taking his medications consistently and started hearing voices and seeing spirits. He couldn’t sleep and got in fights.” says a 2017 article from Undark. After observing Crawford’s deterioration, medical staff requested that he be moved to a psychiatric tier which he never was. The day of Crawford’s death someone brought cocaine to his housing unit, and they were caught on video taking it several times throughout the day while the guards were supposed to be on watch. Crawford’s mother filed a lawsuit against Orleans Parish Sheriff’s Office, the jail’s healthcare provider, and former Orleans Parish Sheriff Marlin Gusman. Colby Crawford is not alone either. From the time Hurricane Katrina happened in 2005 to 2017, 50 inmates died at OJC. Death rates at OJC have been some of the highest in the country ranking near prisons in the largest US cities, and the prison staff has been accused for negligence for a while now. If there is any lesson to be learned from Crawford’s story, it’s that the jail system cannot provide adequate treatment for the mentally ill.

The mental healthcare system in New Orleans had its problems pre-Katrina, but it took a serious decline following the storm. Hurricane Katrina strained the city’s resources. Meanwhile, rates of mental illness doubled according to a study by University of New Orleans department of psychology. Suicide rates in New Orleans tripled post-Katrina. The story of John McCusker, a former Times-Picayune photographer, demonstrates that even some people who had no previous signs of mental illness became unable to function properly after the trauma of the storm.  According to a 2008 case study published by the National Institute of Health, McCusker had spent months documenting the horrific aftermath of Katrina when he began to experience a mental decline. He became depressed and irritable; he eventually took a leave from of absence to recover. Additionally, during this time, he learned that the insurance company would not repay to build his home and had an adverse response to medication he had been put on to relieve his stress during his leave. Soon after, McCusker was pulled over for driving recklessly. When police approached, he rolled down the window of his car and repeatedly yelled at the police to please shoot him. The police did not shoot, and McCusker backed his car up into a police officer pinning him between his car and the police car. The other officers shot McCusker’s back tires, and he drove away only to be pulled over blocks away, pulled out of his car, tased, and arrested. For the duration of his arrest, McCusker continued to resist and beg the police to kill him. He received care in OJC, previously known as Orleans Parish Prison.

Amid the strain that Hurricane Katrina put on the system, the New Orleans area suffered a series of budget cuts and closures of the largest behavioral healthcare providers in the New Orleans region including Charity hospital, New Orleans Adolescent Hospital (NOAH), and Southeastern Louisiana Hospital (SELH). According to a 2009 Louisiana law review, the inability of many New Orleans residents to get and maintain health insurance after the storm contributed to the decline of the mental healthcare system in the city. Many Louisiana residents had issues with Medicaid because they were not in possession of their insurance cards or healthcare providers did not provide the same coverage for healthcare services outside of their hometown or home state. The number of people eligible for Medicaid also increased during this time.

In the years leading up to the COVID-19 pandemic, the behavioral healthcare system showed some improvements, and the sheriff’s office made attempts to train police officers, who are often first responders to mental episodes, to handle those calls more effectively. However, the struggle with lack of beds has remained chronic. Since Katrina, the jail has been the primary provider of behavioral healthcare in New Orleans, and much of the city’s mentally ill population is stuck in the recurrent cycle of unemployment, homelessness, criminalization, substance abuse, treatment, and relapse. Janet Hays, director of Healing Minds NOLA and Assistant Outpatient Treatment of New Orleans, describes the circumstances that made her want to become an advocate for mental health. “After Hurricane Katrina, when the state shut down charity hospital, and we went from almost 200 psych beds to zero overnight. There was this hug uptick in people being channeled into the criminal justice system and under bridges and just caught in these revolving doors of unneeded hospitalizations.”

Homelessness has been an issue in New Orleans for a long time, and it’s very tied to mental illness and the inability for people to get sufficient behavioral healthcare services. Hays explains, “The one thing that we don’t have that we need […] is somewhere to discharge people. They have nowhere to go, and that’s why they keep coming back into the system.” Our system has a tendency to not focus enough on outpatient services after treatment in a psychiatric ward. Without a focus on rehabilitation after hospitalization, many patients end up needing to be hospitalized again.

Following the COVID-19 pandemic, the behavioral healthcare system has experienced another major strain on its resources and a simultaneous increase in rates of mental illness along with a number of unprecedented challenges. As a result, more issues are arising in the quality of mental healthcare in both in the criminal justice system and in the whole city of New Orleans. Lack of beds, unavailability of services, increased demand for behavioral healthcare, and patients’ issues with technology have all caused problems for those with mental illness and their healthcare providers. Robert Bodenmiller, director of the National Alliance of Mental Illness (NAMI) New Orleans, tells of patients’ fears associated with the pandemic and social distancing interfering with their ability to provide treatment. When patients are afraid to leave their houses to go to the pharmacy, it becomes nearly impossible to get them medications that they need. Bodenmiller explains “Many patients do not have computers, and some are too anxious to use technology. Some don’t even have access to the technology needed to provide virtual care.

When Hays advocated for the restoration of Charity hospital to be restored to be another behavioral treatment facility in order to restore the number of hospital beds to levels similar to pre-Katrina, she also hoped that it would be all-inclusive offering places to live, outpatient services, and medications all in one place, but the state and Louisiana State University voted to turn the abandoned hospital into condos. The purpose of offering all-inclusive services is that maintaining stable housing and transportation is one of the biggest struggles of the mentally ill. For this reason, NAMI focuses treatment programs on building community and a sense of independence and purpose with their “clubhouse model.” Hays and Bodenmiller both agree that a strong support system, a sense of purpose, and a community are very important in the healing process. “We need some sort of central place where folks who have severe life challenges related to cognitive disorders to be able to find the programs and services that they need in one place.” says Hays.

While communicating with policymakers about Charity hospital, Hays experienced resistance to the concept of this congregate living style. “There’s this attitude that everybody if you give them support can lie independently and care for themselves, and that’s not even true for people that don’t have serious mental illnesses let alone people that do.” A good portion of people who suffer from mental illness do not know that they are sick, go untreated, commit a crime, and end up in the prison system. “They end up criminalized or homeless and punished for their behavior which is really inhumane especially since the disease is a no-fault disease.” To address this issue, Janet Hays has been advocating for a few policy changes that could help more people break this cycle.

She wants to enact a redefine the grave disability standard to include psychiatric deterioration enabling the mentally ill to get help even if they do not know they are sick. This policy change could have helped Shante Wade get help before the incident at University medical center.

“The other policy change that we would like to see is – there’s a federal waiver that would allow the federal government to subsidize the states to increase psychiatric bed capacity. It allows for longer stays in hospitals so individuals can get more specialized treatment and care. The effect of that is if a person is in a bed longer then that’s a bed that nobody else can use so it incentivizes the building of additional psychiatric beds that can be operationalized by federal money.” The waiver has already been implemented for people with substance abuse disorders but not for people with serious mental illness.

Fixing the behavioral healthcare system has already been a hard enough task for advocates due to prejudices about people with mental illness. “There’s an idea that mentally ill people aren’t valuable to society and a lack of understanding that serious mental illness is an illness.” With the additional strain on resources and new issues that have come up with the pandemic, getting policymakers to prioritize behavioral healthcare will prove to be even more difficult.

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