Homelessness is a longstanding problem in Los Angeles County, and the data shows that it is getting worse. Between 2013 and 2015 alone, the homeless population in Los Angeles increased by 12% (Jamison et al., 2015). In many cases, these homeless individuals are struggling with mental illness, substance abuse, or both. These problems often go untreated, which can cause the individual to engage in criminal activity for financial purposes, which in turn leads to incarceration. Prevalence of serious mental illness among prisoners has shown to be as high as 14.5% for men and 31% for women (Steadman at al., 2002). Individuals often cycle through homelessness and incarceration, which is called the revolving door phenomenon (Wuerker & Keenan, 2002). There are many nonprofits in the Los Angeles area that aim to ameliorate this problem, but they often struggle financially due to a multitude of factors. This study aims to map the mental health services available for homeless individuals who live in or near Downtown Los Angeles’ Skid Row district to further understand what resources are available for utilization.
Jennifer Bailey graduated from USC this past May with a B.A. in Social Science with an Emphasis in Psychology with minors in Spanish and Healthcare Studies. While at USC, she completed her senior thesis on mental health after first being exposed to the issue during her trip to Guatemala through Problems Without Passports in the summer of 2015. She is currently a first year medical student at the Icahn School of Medicine at Mount Sinai in New York City and plans to incorporate public health into whatever specialty she chooses.
Mental Illness Among the Homeless and Incarcerated of Los Angeles
Homelessness is a longstanding problem in Los Angeles County, and the data shows that it is getting worse. Between 2013 and 2015 alone, the homeless population in Los Angeles increased by 12% (Jamison et al., 2015). In many cases, these homeless individuals are struggling with mental illness, substance abuse, or both. These problems often go untreated, which can cause the individual to engage in criminal activity for financial purposes, which in turn leads to incarceration. Prevalence of serious mental illness among prisoners has shown to be as high as 14.5% for men and 31% for women (Steadman at al., 2002). Individuals often cycle through homelessness and incarceration, which is called the revolving door phenomenon (Wuerker & Keenan, 2002). There are many nonprofits in the Los Angeles area that aim to ameliorate this problem, but they often struggle financially due to a multitude of factors. This study aims to map the mental health services available for homeless individuals who live in or near Downtown Los Angeles’ Skid Row district to further understand what resources are available for utilization. In addition, the clinicians, advocates, and law enforcement officers behind these resources will be interviewed to further understand the problems faced by this population, the solutions proposed, and the barriers they face. This thesis proposes to detail the issue of homelessness and incarceration among those with severe mental illness in Los Angeles County. Ultimately, the goal of this thesis is to identify options for improving care for those in a population who deeply need it. The prevalence of severe mental illness among the homeless and incarcerated is a problem too significant to ignore.
Review of Related Literature
The issue of mental illness among the homeless and incarcerated has long been a problem in the United States. Specifically, the roots of the problem can be traced to the deinstitutionalization movement that took place following the passage of the federal Mental Health Act of 1963. The bill aimed to reduce the numbers of Americans with mental illness who were housed in psychiatric hospitals, often indefinitely. Instead, the act promised community mental health centers throughout the United States, that would allow individuals with mental illness to receive their treatment on an outpatient basis and remain fully integrated into society (Baillaregon et al., 2009). However, most of these community centers were never built. Instead, individuals of different socioeconomic status have different levels of access to mental health care, with lower income individuals receiving less mental healthcare services (Alegria, 2000). As a result, many individuals with mental illness who need care do not receive it, and instead become homeless. Past research has shown that individuals with more severe mental illnesses, such as schizophrenia and bipolar disorder, are more likely to become homeless compared to individuals with less severe diagnoses, such as depression (Folsom et al., 2005). Living on the fringes of society, they cycle through incarceration and homelessness, never truly receiving the care they need. In previous research, several factors have emerged as crucial in allowing this cycle to continue.
Historically, those with the greatest need for mental health care have not had access to insurance. Until the passage of the Affordable Care Act (ACA) in 2010, low-income adults aged18-64 who did not receive insurance through an employer were often left without insurance. In California, these adults were ineligible for Medi-Cal insurance, unless they had a severe disability. Even those considered severely disabled due to mental illness often were not covered, as enrollment was a tedious process involving paperwork that many did not understand (Farr, 1984). This was seen to be a particular problem of the homeless populations, as they lacked insurance and instead utilized emergency treatment services and inpatient hospitalization more than those who were not homeless (Folsom et al., 2005). Even presently, following the passage of the ACA, many eligible individuals are not enrolled in an insurance program, as the online marketplace can be tedious, incomprehensible, and inaccessible to homeless individuals (Fryling, 2015). In fact, many have not even heard of the Affordable Care Act.
Another barrier to treatment that must be considered is the issue of trust. Homeless individuals often fear persecution by the police, and therefore are reluctant to move beyond the areas that they feel are safe (Farr, 1984). This suggests that efforts should be directed toward the implementation of services in areas where the population density of homeless individuals is the greatest. Furthermore, the issue of trust must be considered even when the individuals have reached the clinician for treatment. In the past, clinicians have stated that with some clients, particularly those with paranoid schizophrenia, it may take up to a year to gain their trust (Wuerker & Keenan, 2002). In addition to individuals continuing to receive care upon release from inpatient clinics, attention must be paid to the stability of their relationship with their clinician.
An individual beginning to receive care for mental illness is only the first step on the long road to recovery and successful reintegration into society. For this reason, continuity of care is crucial. Past research by Wuerker and Keenan examined a population of individuals from Skid Row receiving care through Skid Row Mental Health. They found that upon release, only half of patients came to the service again for care (2002). While many of these individuals did not have diagnoses of psychosis and instead had less severe diagnoses, it is still likely that they needed some type of care to continue to stay healthy following treatment. Continuity of care for homeless populations is known to be difficult, as the population is generally very mobile (Farr, 1984). In these cases, there was no continuity of care, because even if these individuals received care from somewhere else, they did not have patient-provider continuity, which is important, especially in terms of trust. In the future, this must be considered for mental health care services directed at homeless populations.
Unfortunately, many individuals with mental illness end up imprisoned. In a study of over 800 prisoners, Steadman and colleagues found that 14.5% of male inmates and 31% of female inmates had a serious mental disorder, which included only schizophrenia, bipolar disorder, and major depression (2002). Furthermore, in a study of nearly 8,000 inmates in the Texas Department of Criminal Justice, inmates with the aforementioned mental illnesses were found to have higher rates of recidivism than other inmates (Baillaregon et al., 2009). In addition, inmates with schizophrenia or another psychotic disorder had higher rates of prevalence for violent crimes and drug possession. This research delves into the consequences for those with severe mental illness who do not receive treatment. They often reach levels of psychosis in which they have lost touch with reality. In these cases, their hallucinations and delusions can lead them to behave in violent ways which then lead to arrest. However, it is important to note that nearly 80% of those with these severe mental illnesses are nonviolent (Baillaregon et al., 2009). Moreover, many cope with their mental illness through drug abuse when no other treatment outlets seem to be available. Therefore, future research must focus on improving pathways to care for these individuals. This way, they can receive care before they end up incarcerated for many years.
Other Western countries have attempted to tackle the problems of homelessness and incarceration among those with mental illness. One meta-analysis of these services in European capitals as part of the PROMO Project found that the barriers seen in these cities were quite similar to the problems faced in the United States (Canavan et al., 2012). For example, the experts on mental health among the homeless reported that the most important barriers to overcome were the chaotic life circumstances of the homeless population and their mobility, their unwillingness to engage in health services due to lack of trust, lack of insurance, and substance abuse. These issues do not seem to be resolved simply by the national universal healthcare systems that exist in these countries. Instead, the homeless population continues to receive subpar healthcare and individuals are often turned away for mental health treatment due to problems such as substance abuse, which often co-occurs with mental illness (Canavan, 2012). In addition, these individuals also often make their way into the criminal justice system, which was observed in a Dutch study by Dorn and colleagues (2013). Screening for mental health issues is not required upon intake in The Netherlands, but when inmates were screened as a part of this study, nearly 40% tested positive on the Brief Jail Mental Health Screen, a result that suggests a need for further evaluation. This percentage is much higher than what was seen in a comparable study in the United States. Additionally, those who screened positive were more likely to lack a permanent address, a fact that suggests, but does not confirm, homelessness. It seems that issues of mental health among homeless and incarcerated populations is still a problem in these nations.
Recently, there appears to have been an increase in awareness of the problem of homelessness and incarceration among those with severe mental illness in the United States that has spread to mainstream publications. In June 2015, an in-depth profile of Cook County Jail in Chicago, deemed “America’s Largest Mental Health Hospital”, appeared in The Atlantic (Ford, 2015). The article focuses on the failings of our mental health system and the county’s attempt to cope. Correctional officers receive 60 hours of advanced mental health training before starting the job and there is a specific Mental Health Transition Center designed to help inmates adjust after their release. Often, there are fewer mental health services available outside of jails and prisons, a fact which speaks to the systemic issues found within the nation’s mental healthcare resources.
This has also been recently exemplified by the deaths of mentally ill individuals on Skid Row. In July, 2015 GQ published an article countering the Los Angeles Police Department’s statements regarding the death of Charly Keunang, a Cameroonian immigrant who had previously been hospitalized for mental illness (Sharlet, 2015). The LAPD claimed that the officer shot Keunang in self-defense as he was reaching for the officer’s gun, a statement which has since been put into doubt. Furthermore, when put into the context of the shootings of Carlos Ocana and Ezell Ford, two men who each also had a history of mental illness, a pattern of misunderstanding on the part of LAPD regarding homeless individuals with mental illness emerges (Sharlet, 2015).
Most recently, on September 22, 2015, the Los Angeles City Council declared a state of emergency on homelessness and pledged 100 million dollars to address the problem (Jamison et al., 2015). While the announcement was criticized for a lack of specificity, if implemented, it could provide a sense of stability to the many homeless with mental illness who would have newfound access to housing. Its true impact remains to be seen, however, and it seems that for the time being, homeless individuals will have to rely on nonprofit organizations to help them receive the care that they need.
For this thesis, interviews were conducted with healthcare providers who work on Skid Row and with the incarcerated. They were affiliated with organizations including Homeless Healthcare Los Angeles and the Downtown Women’s Center, as well as the Los Angeles County Department of Health. Interviews were structured around the key issues the healthcare providers face when working with these populations and changes they would make to the system if more resources were available. All interviews were conducted in person, in order to also observe the clinic and the surrounding environment. The main conclusions from these interviews will be presented in the Findings section.
Following interviews with healthcare providers, the major issues in providing healthcare can be categorized in terms of co-occurring problems for the populations themselves and systemic barriers. For these providers, caring for the homeless and incarcerated presents a unique set of challenges, though their work ultimately has an impact on many residents of Los Angeles.
The homeless and incarcerated of Los Angeles face several other barriers that make it difficult for them to access mental healthcare. The problem of drug abuse was mentioned at every interview. According to Mark Casanova, Executive Director of Homeless Healthcare Los Angeles (HHCLA), the homeless often face judgment from the very individuals who are providing them with care.
“A lot of people who work with this population lack basic kindness. They also believe that drugs are inherently bad which they are not. People use drugs for a reason. They make you feel good. So many people who work with the homeless are focused on getting them to quit using drugs, which isn’t going to happen.” (M. Casanova, Interview, January 15, 2016)
Because of this view, only recently has funding been given to non-profit organizations with a focus on harm reduction. This is one of the main focuses of HHCLA, which has a syringe exchange clinic located on Skid Row. Here, individuals who use drugs can turn in used syringes and receive the same amount in return, plus five new syringes daily. The service is completely free and anonymous, as the intake form only asks for a respondent’s initials, age, ethnicity, whether they are a new visitor, and what drugs they use (HHCLA Center for Harm Reduction, Clinic Observation, January 28, 2016). Overdose kits are also given to clients, with an explanation on how to use them and a doctor is available to treat abscesses for free. Programming like this improves the quality of life for homeless individuals who also use drugs. When they do not have to worry about an untreated wound or where to get clean syringes, they can use drugs safely, removing a barrier to receiving mental healthcare.
However, providers that were interviewed also spoke of the need to do better. Both Mr. Casanova and Dr. Rolando Tringale, a physician at the HHCLA’s Center for Harm Reduction on Skid Row, spoke of the need for supervised injection facilities, where drug users can inject in a public place and receive care in the event of an overdose. While these facilities are still controversial in the United States, HHCLA has already taken steps toward this. At their syringe exchange clinic within Skid Row, drug users have access to a private bathroom. However, a timer is set for five minutes when someone enters, after which they are checked on to be sure that they did not overdose (HHCLA Center for Harm Reduction, Clinic Observation, January 28, 2016). Dr. Tringale reaffirmed the need for these facilities. “[Drug users] need a safe space to use their drug of choice. We know they aren’t going to stop using drugs so we need to focus on helping them do it in a safe way,” (R. Tringale, Interview, February 5, 2016).
Furthermore, many of the homeless do not speak English as their native language and face linguistic and cultural barriers. According to Stephanie Pozuelos, a social work graduate student interning at the Downtown Women’s Center (DWC), there is a need for more Spanish speaking clinicians, as many women at DWC do not speak English. “We have a group of women that isolate themselves from other ladies in the center because they don’t speak English and can’t understand the day to day activities” (S. Pozuelos, Interview, February 2, 2016). For therapy to be most effective for women like these, it will have to be conducted in Spanish. At DWC, mental health services are limited and are mostly short-term. She is currently the only provider able to conduct therapy in Spanish and the waiting list is extensive. Furthermore, navigating mental health treatment for those from different cultural backgrounds can also be challenging. “It’s a matter of breaking stigmas and stereotypes surrounding mental health,” she said. Because of this, DWC has placed an emphasis on adding more culturally and linguistically appropriate services in its Strategic Goals for 2016.
Both the homeless and incarcerated are mobile populations, which also makes it harder to access mental health treatment. According to Dr. Tringale, the lack of housing for these clients is the biggest barrier to treatment. “Specifically, outpatient care is the biggest need because individuals who are homeless may not have a home, but they have a lot of stuff that they may not want to let go. If they want to do a program that requires them to leave, where is that all going to go? They can’t afford a storage unit but they develop attachment to things like all human beings.” At HHCLA, clients can have their mail sent there and check it daily, which adds a sense of stability. However, for such a mobile population, it is hard to book appointments in advance because they do not plan far in advance. “Asking one of these individuals to make an appointment in advance and show up three weeks later is like finding a needle in a haystack with this population,” Dr. Tringale said. For this population to receive effective care, the system will need to adapt to its needs.
It seems that this adaptation is in process. The Housing First Model, which gives homeless men and women homes without any preconditions of sobriety or attendance in therapy has shown to be effective. Organizations such as LAMP in Los Angeles have adopted this model, which has been recognized as a best practice by the United States Department of Housing and Urban Development. The model was first used in New York in 1992 and has since spread throughout the country (Department of Housing and Urban Development, 2007).
Similarly, those in the Los Angeles County jail system are difficult to access for care. The jail system is the largest in the United States, and houses between 15,000 to 20,000 inmates at a time, two-thirds of whom have a serious medical condition (J. Ryu, Interview, February 22, 2016). According to Dr. Jenica Ryu, a family medicine physician who works both on Skid Row at the JWCH Center for Community Health and within the Los Angeles County jails, the medical system is defunct. Coordination of care is difficult and must be balanced with custody needs, which often take priority. “The reason they’re there is to be locked up. You have to be able to work with the deputies, the officers, and the sheriffs to find a way to balance behavior control and medicine.” Furthermore, patients themselves can be a barrier to their own treatment. Often, their priorities are not with their medical conditions. “These patients are extremely chaotic and they have competing priorities. What is a priority to them is often not their medical condition,” she said. Additionally, as inmates stay in jail for a much shorter time than prison, there is a rapid turnover of inmates, which must be considered in their care. Those with mental illness will not be treated by the same clinician over the long-term. Similar to the homeless, the incarcerated are highly mobile, which makes caring for them even harder.
An important systemic issue is that services for the homeless in Los Angeles are located in a multitude of different locations. This is not limited to mental health; the homeless who need to utilize mental health resources often also need primary healthcare, substance abuse resources, as well as social services such as help with enrolling in disability payments. The clinic where Dr. Ryu works is an example of this model, but unfortunately this is not standard. “Not enough services are co-located. That is why [the JWCH Center for Community Health] is so great. To often medical services, social services, food banks, HIV care, and mental healthcare are all separate when these people often have co-morbidities. It is so much better to co-locate services and guide patients.” When an individual is attempting to gain access to necessary services, it can be difficult to figure out where to go for each resource.
Similarly, the waiting time for these services is often long. While patients in a crisis can be treated within a few hours, such as at the Exodus Clinic near the Los Angeles County Hospital, healthcare providers still feel that this is too long. “They can go to Exodus Clinic but the wait is still three to five hours, which is a long time to wait for someone who is severely mentally ill, addicted to drugs, or both,” Dr. Tringale said. Furthermore, when a client is more stable, their wait can be much longer. Emergencies take priority, so other patients end up waiting. While this makes sense, this is difficult for a highly mobile population with low health literacy. This requires providers to be more flexible. Dr. Ryu added to this point: “Flexible care is very important in an unstably housed population. They aren’t going to follow your normal rules. They aren’t going to check in at the normal times and they are going to be needy. Instead, there is this idea of practice transformation, which is making your system of care open to the needs of this population.”
Summary, Recommendations, Conclusions
Homelessness and incarceration among the mentally ill had clear roots in the deinstitutionalization movement of the mid-twentieth century. While institutionalizing those with mental illness had many consequences of its own, eliminating these facilities left many individuals with mental illness with no place to go. Instead, the homeless population increased rapidly and in some cases they formed communities, such as Skid Row in Downtown Los Angeles. These communities, and the homeless in general, have become so isolated that issues of trust developed. Law enforcement officers have found it difficult to gain the trust of the homelessness, who fear police persecution. Healthcare providers face similar barriers, which prevents treatment altogether or delays it until an emergency has occurred. Even in cases when the homeless receive treatment, continuity of care is often lacking.
The complexities of insurance are difficult for many average Americans to understand, so understandably this is much worse for the homeless. The Affordable Care Act has expanded coverage, but if a person does not understand that they need coverage, this means nothing. Many of the individuals on Skid Row do not possess identification, which complicates the enrollment process. In situations where the aforementioned factors are present, incarceration is often an unfortunate result. Individuals in custody are often moved between crowded facilities in which many other inmates are suffering from a serious health issue. This does not do them any favors and often mental illness among inmates goes undiagnosed or untreated. The overarching issue at hand is the issue of homelessness itself. As many of the clinicians interviewed stated, it is difficult to access the healthcare system regularly without a stable address. As such, the Housing First Model has grown in popularity. It is a fundamental aspect of the recommendations posed below.
Recommendations to Improve Mental Health Care Within Skid Row
1. Allocate More Resources to Continue Implementation of Housing First Model: Of the services listed in the previous map of mental health care services, all of them that also provide access to housing resources emphasize that they practice Housing First. The stability that permanent housing provides makes it much easier to take care of mental health issues, substance abuse problems, or any other health concerns. The client will have a permanent address and will not have to worry about where to spend each night. This could be expanded by allocating resources spent on supportive resources toward solving the primary problem, a lack of housing, and the screening process made more efficient to accommodate more homeless individuals. The bureaucratic barriers that now seem significant can be overcome with more funding and staff; the permanent housing units of DWC are not full, but women are going through the screening process of the Coordinated Entry System (S. Pozuelos, Interview, February 2, 2016).
2. Create More Public/Private Partnership Clinics: A public/private partnership allows for more resources in a single clinic than a county clinic or private clinic alone could provide. JWCH Center for Community Health, the clinic in which Dr. Ryu works is a public/private partnership between the Los Angeles County Department of Health and JWCH. In this clinic, there are medical resources, such as HIV care, optometry, and mental healthcare, along with ancillary resources such as substance abuse treatment and assistance in enrolling in supplementary security income (J. Ryu, Interview, February 22, 2016). More clinics based on this model will allow clients to address all of their needs in a single visit, which is much more aligned with the lifestyle of this population.
3. Address Linguistic and Cultural Barriers: If a client only speaks Spanish and the waiting list for therapy in Spanish exceeds a reasonable length of time, that client will likely never get the care they need. This problem does not have a simple solution; providers cannot become instantly bilingual. Instead, focus should be directed to educating physicians-in-training and other healthcare providers early on in their careers about the needs of this population. The providers interviewed for this thesis seemed to stumble upon caring for the homeless, beginning with a fellowship following medical residency or an interest in a specialty relevant to the homeless, such as addiction medicine. On the other hand, cultural barriers can be addressed more directly and manifest in a multitude of ways. One example of this is the stigma surrounding mental illness that prevents those in need of care from seeking it. This can be dealt with through public health campaigns in places where this population congregates, such as the bus shelter areas on Skid Row. These campaigns could have messages in both English and Spanish with themes that explain mental illness in a relatable way.
4. Create Supervised Injection Facilities: This proposal has not gained much traction in the United States due to the fact that opponents believe it condones drug use. Individuals will use drugs regardless, but placing a supervised injection facility within Skid Row would help them to do it in a safe way. This facility would provide clean syringes and would be staffed with clinicians who could help in the event of an overdose. Additionally, detox resources would be available for clients who wanted to cut back on their use of drugs or quit altogether, as well as information about general health clinics. While this idea does not relate directly to mental health, it is important to consider because people who use drugs in an unsafe way often do so to self-medicate an untreated illness (Baillaregon et al., 2009). Using drugs in a facility like this would introduce someone who uses drugs to the healthcare system, hopefully building a gradual trust that would allow them to come in for other issues, such as an untreated mental illness.
5. Develop Tracking System for Utilization of Mental Health Services: Tracking of the homeless is already done. The Los Angeles Homeless Services Authority currently sends out more than 7,000 people to count the number of homeless in the city (Los Angeles Homeless Services Authority, 2016). When utilizing services at some centers, homeless individuals are required to fill out the VI-SPDAT questionnaire (HHCLA Center for Harm Reduction, Clinic Observation, January 28, 2016). The results of this questionnaire are designed to be input into a system that all providers can access. The Homeless Management Information System (HMIS) is currently used and records information about an individual and the services they utilize at each place, but the use of this service needs to be expanded and standardized (S. Pozuelos, Interview, February 2, 2016). A similar system could be created for utilization of mental health services specifically that documented the care a client received on each occasion. Therefore, if someone who is homeless uses several different services, providers will at least know what has been done in the past without having to start from the beginning. While this does not provide the trust that traditional continuity of care provides, this will allow clinicians to provide the best care with more information on past treatment and ongoing health issues.
These proposals are all subject to limitations. Financial constraints will be significant, especially in the development of new clinics or supervised injection facilities. However, a public health campaign focused on mental illness does not seem out of reach. Furthermore, a tracking system could be completely computer based and low-cost, even modifying the HMIS currently in place. Sending clinicians in training to Skid Row actually would be helpful in terms of budgeting; they could assist in providing care in a system that is quite backlogged.
Based on the research and interviews conducted for this thesis, these recommendations seem to best address the problems identified. While no end to homelessness or even mental illness among the homeless is in sight, it is important to acknowledge the efforts of healthcare providers on Skid Row. In researching this thesis, it became apparent just how much clients trust and rely on these clinicians. Dr. Ryu discussed seeing the same patients over time and even having some resurface after several years. “Every once in a while you’ll see a patient who you haven’t seen in years. It’s really great because sometimes they are in a different place in their lives and sometimes that means that they are more open to treatment.” Similarly, the social workers at the syringe exchange clinic spoke of seeing the same patients come in every day. The strength of their relationship was apparent upon observation of how they joked around or how the client would discuss the whereabouts of friends who the social workers also knew. While there are undoubtedly changes that could be made to improve the system, there is great work being done on a daily basis by providers who care for those cast aside by so many others.
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