Homelessness and Mental Illness II
Price of Paradise · Hawaii Public Radio · aired 1996-04-28
Guests: Barry Carlton (Director, Queen's Medical Center Counseling and Clinical Service; Associate Professor of Psychiatry, UH Medical School); Margaret Copi (psychiatrist); Sharon Black (Coordinator, Honolulu Police Department Project Outreach)
Duration: 1:04:11

[00:00:00] Randall Roth: Good morning. This is Randy Roth, host of the Price of Paradise radio show. Everyone who works to bring this program to you is a volunteer who believes in the importance of lively and informed public dialogue. Our airtime is paid for by the Hawaii Community Foundation, an organization that encourages grass-roots efforts to improve the quality of life in Hawaii and that manages charitable funds with efficiency and compassion. Today is the second installment in our two-part series on mental illness. Dr. Margaret Cappy is with me in the studio and Dr. Barry Carlton is with us by phone. Barry is an associate professor of psychiatry in the John A. Burns School of Medicine at the University of Hawaii.

[00:01:17] Randall Roth: He also is an attending physician at the Queen's Medical Center and the Castle Medical Center as well, and is the director of Queen's counseling and clinical service. Margaret has worked for the last six years as a psychiatrist with the Kalihi-Palama Health Center's healthcare for the homeless project. Since last December, she also has worked at the new Beretania Street Safe Haven residence for homeless and mentally ill persons. She received a National Alliance for the Mentally Ill exemplary psychiatrist award in 1993 and the Mental Health Association in Hawaii Community Service Award in 1994. Margaret, good morning. Good morning. And Barry, you're on the line and I'm going to go to Barry in just a minute. But, Margaret, why don't you begin by telling us just a little bit about the number of people who are on the streets right now with mental illness and whether that number is larger than it once was, or smaller, and just give us a little bit of background on street people with mental illness.

[00:02:22] Margaret Copi: The Kalihi-Palama Health Center, Healthcare for the Homeless Project has come up with a number of approximately 3,000 homeless people with mental illness in the state of Hawaii, and this is basically an extrapolation from the number of people that we see in our project and putting that together with numbers that have been put forward by SAMS and the Hawaii Housing Authority. We think there are 10,000 homeless people overall and about a third of those have severe mental illness.

[00:02:48] Randall Roth: Have there always been that many people with severe mental illness, and we've simply not seen them? They haven't been as visible? I'm under the impression that they're more visible now than before. Is that true?

[00:03:01] Margaret Copi: Yes, there are more people on the street now and there are several different reasons for that. One has to do with the fact that since the sixties, less and less people with mental illness have been allowed to stay in state hospitals across the country and including here in Hawaii. And the other reason is that people who are poor and have to find very inexpensive housing, increasingly have been pushed out onto the street all over the country as SROs and other cheap housing stock disappears.

[00:03:40] Randall Roth: I'm under the impression that part of it, too, is that at some time in the past, and I don't know how far back we have to go, but there was a different attitude that if a person was mentally ill or been diagnosed by a physician as mentally ill, that we were a little bit more quick to force treatment, force medication, as opposed to now, I'm under the impression that if that person doesn't pose a danger to himself, herself, or to others, if that person doesn't want to take medication, doesn't want to move indoors from the park or wherever they're living, it's my impression that we, as a society, have decided to go along with that more so now than in the past.

[00:03:53] Margaret Copi: The forcing of treatment is another theme that exists in addition to the exiting people out of state hospitals. We thought in the fifties and sixties, when psychiatric medications first became more useful, that these medications would eradicate mental illness and people wouldn't need to be in the hospital, that they'd be just fine. And then after everybody got out onto the street on their Thorazine, we realized that there were more symptoms that didn't go away. Even when the medication worked for their hallucinations and their delusions, there were a lot of problems with people being able to formulate plans and carry them out because several different parts of the brain are affected. The notion of forcing treatment became an issue because there were so many people on the street that were obviously sick and needed treatment.

[00:04:57] Margaret Copi: There's a balancing act between realizing that people are not competent to make decisions and forcing them to go along with it, which is more of a paternalistic role for the state, versus that people that everybody including homeless people have civil liberties and a right to refuse intrusive interventions, such as medication. Your article in this morning's newspaper points out that oftentimes people, because of their mental illness, don't want to take their medication.

[00:05:23] Randall Roth: If it was a child that was sick and we wanted that child to get well, just because they didn't want us to reset the leg or whatever it would take to help them get well, we would in one way or another force a treatment on a child. And yet we don't on somebody who's mentally ill.

[00:05:36] Margaret Copi: They're considered competent until they're adjudicated to be incompetent in a legal proceeding. And I've done quite a lot of attempting to go through that proceeding and have people declared to be incompetent and have a guardian assigned through the Office of the Public Guardian. It's a very long, arduous process. And then even that guardian needs another court hearing in order to be given permission to actually make treatment decisions. In other states, they have programs such as conservatorship in which someone has an assigned neutral party who can make treatment decisions for them. The problem with using that in Hawaii is that the conservatorship is based on someone having been found to be gravely disabled over a period of two years or so.

[00:06:54] Margaret Copi: And then it's thought that they've been incompetent and gravely disabled for two years, it's time for somebody to take them in hand and provide treatment when it's needed. Whereas here in Hawaii, we haven't been able to begin to use the grave disability standard because there is some resistance on the part of the family court judges who feel that it's not constitutional. So we haven't been able to try to use this in order to establish over time that someone needs intervention.

[00:07:33] Randall Roth: So even if someone has been determined incompetent and has a court-appointed guardian, unless that person poses an imminent danger to themselves or to others, treatment cannot be forced upon them.

[00:07:46] Margaret Copi: That's correct.

[00:07:59] Randall Roth: Okay. Well, on the phone, we have Barry Carlton, who is a psychiatrist who works out of both Queen's and Castle Medical Centers. Barry, can you hear me? Sure. Any thoughts to add to what you've been hearing from Dr. Margaret Cappy?

[00:08:25] Barry Carlton: I think Margaret and I are often on the same side of the street, although I don't know if she's including in the homeless, mentally ill substance abuse group that the total homeless population, I guess, has been estimated as Margaret said, between 10,000 and 12,000 of which 30% are going to be the homeless, mentally ill, and other 30% maybe people who, by virtue of their use of substances like alcohol or methamphetamine, are also mentally ill and present with psychiatric disturbance, but in some definitions, don't aren't usually counted as mentally ill. I think the other thing that happened with the homeless, in addition to what Margaret said and in addition to medications not being totally perfect, is that there was an assumption that with the use of medications, you could quote empty the state hospitals and no one else would get ill. And that isn't quite, that isn't quite correct, that even with a good response to medicine, only 80% of people who take their medicine respond positively.

[00:08:51] Barry Carlton: So there always is going to be a kind of an up and coming population, or a new group of people who develop a disabling illness.

[00:09:04] Randall Roth: Barry, is there something about the system that's broken now? I see you and Margaret as being on the same side of the street on most of these issues, but I see her current position at least as being one of being more or less an advocate for the homeless, mentally ill, and among other things, she's trying to get more treatment in a variety of ways. And you want to help people who are homeless, mentally ill, but as I understand it, you've got the institution to be concerned about and there are limited resources. Is there a tension there that we as a society aren't dealing with very well right now?

[00:09:42] Barry Carlton: I think there's a, there's a not so much a tension between health professionals, because everything that Margaret said about treatment and problems with the length of time it takes to get guardianship so people can take medication and the problems with the definition of what is dangerousness, I think she and I would both agree with. I think where the difficulty is in the society, is that we can't have it both ways. For example, when people who aren't mentally ill are a criminal or annoying, but not imminently dangerous, there is a wish that they not be on the streets. Yet at the same time, we don't provide the facilities, either alternative housing, money for housing, or the techniques to have treatment.

[00:10:34] Barry Carlton: And we don't want criminals on our street and we don't want people who are ill in jail, yet we don't provide the resources to, to help the folk. And then as the people further deteriorate, then it's an expectation that very expensive care, that is hospital care, will then fix people, which of course, we don't. Hospitals respond well to crises and help people stabilize, but then unless resources are provided when they leave, then there is there's a revolving door. And what we have at the moment is episodic high cost care that people think they're not paying for, that is, it's not in the tax dollar, it's not general assistance, but is in the healthcare premium dollar because the cost of delivering care is then spread amongst every other patient in the hospital or statewide in the cost of higher healthcare dollars.

[00:11:26] Randall Roth: So you're the middleman. If you've got to take care of somebody in a way that's going to be terribly expensive, that ends up being passed on to everyone.

[00:11:39] Barry Carlton: That's certainly true if, for example, someone becomes there's a balance between how you feel about yourself, the state of your illness and your circumstances and time as to what your level of symptoms are. So if suddenly you become afraid, you're going to be homeless or you're not going to be able to provide for yourself, you then activate the illness, you exacerbate it, you make it worse. Often, or helpful, often, that will result in the patient becoming acutely ill, they then become hospitalized at a cost of between $800 and $1,000 a day because in order to restore health, you need lots of people. Whereas if you had prevented illness by providing adequate housing or whatever, you would decrease the person's stress tension and then make it less likely that they would be ill.

[00:12:31] Randall Roth: We also have on the line Sharon Black. Sharon is the coordinator of the Honolulu Police Department's project outreach and Sharon has an article that is in this morning's advertiser. Sharon, can you hear me?

[00:12:44] Sharon Black: Yes, I can.

[00:12:57] Randall Roth: Were you able to hear the comments of Margaret Cappy and Barry Carlton?

[00:13:10] Sharon Black: I got some of it, yeah.

[00:13:23] Randall Roth: From your piece in the newspaper, I get the impression that your main theme is that this area ought to be decriminalized, that people who are homeless and mentally ill shouldn't be treated like criminals, even if they're doing something that's technically a crime, there ought to be a recognition that the problem is that they're mentally ill, not that they've done whatever it might be that technically is a crime. Can you tell us just a little bit about how Project Outreach works?

[00:13:49] Sharon Black: Basically what it is, is a one stop, 21, 24 hour stop, one stop, cop stop. Basically, I think what happens is that many a times by the time the officers are called, what's happening is they're getting either a complaint from the community or that this individual is behaving in such a manner that comes to the attention to where police are called. So it's not like we're going out there necessarily looking for these individuals, but they're coming to our attention through the 911 system because of some type of behavior. And what happens is in many cases, we try to get them help, immediate help, especially if they cross the line, and in most cases they have, to where they're imminently dangerous to self or others.

[00:14:40] Sharon Black: So it's very frustrating because we find that what we do is we try to use the law that already exists to get these individuals into treatment. And then you have to use the criminal justice system to get something done, but you don't want to put them in jail. It doesn't make sense, I think it's extremely cruel to put them in jail because it's not helping the individual out with illness. I think what Project Outreach tries to do is to go out there, talk to these individuals, try to encourage them to get into a facility, but unfortunately, even for us, it's frustrating at times because we're not always able to. There's all kinds of different solutions, but it takes a lot of creativeness to come up with it in a system that seems to have closed down everywhere and getting these individuals help.

[00:15:45] Randall Roth: It sounds like at least with Project Outreach, you've decided to look at this as a social rather than criminal problem.

[00:15:58] Sharon Black: Yeah, I think it's what the police department views it as is a decriminalization. You know, instead of us arresting and rearresting, you know, because the illness is still there, it doesn't make any sense. I think what's frustrating for officers especially is you keep seeing sometimes the same individuals repeatedly and you're trying to go for that long term solution so that you can really get them the help that they need.

[00:16:37] Randall Roth: Sharon, thank you very much. I appreciate you're being available to us this morning. You're listening to the Price of Paradise Radio Show. Our topic this morning is Mentally Ill Street People. If you'd like to ask a question or make a comment, call us at 955-8821. If you're on a neighbor island, the number is 1-800-955-8821. Especially if you've personally been touched by this topic, if you have a family member, or in any other way, have had some experience with this, we would very much appreciate you sharing that with us. Well, Margaret, as I think about this topic, one of the things that I think has to be addressed is that there is I think at least a sense of of danger when when I'm among homeless, mentally ill people.

[00:17:55] Randall Roth: I feel that some of them, I think, are dangerous or potentially dangerous, and I worry about that. What do you think?

[00:18:21] Margaret Copi: There's a very significant stigma attached to persons with mental illness. And this is largely because the behavior often is odd, bizarre. People do unexpected things and then you get worried that what are they going to do next? And you can't predict what they're going to do.

[00:19:00] Sharon Black: when someone is untreated and has a severe mental illness, many times they're frightened. They're they're they're terribly frightened, and and this fear will telegraph to the people around them. So the people around them become frightened as well.

[00:19:18] Speaker 1: are you suggesting that that they really aren't dangerous, um that this is a misperception?

[00:19:36] Sharon Black: Well, some of them are dangerous and some are not, just like other people in the community. But persons with mental illness aren't any more dangerous as a group than uh other than the rest of the population. Um In fact, on the street, the people with mental illness are victimized far, far more frequently than they hurt other people. Um there was a study in July 95 that was published where about 40% of the people who were homeless um had been robbed, assaulted, or or raped on the street and I see this a lot.

[00:20:12] Speaker 1: It it obviously would be a very, very difficult life and and I think in many instances, um it's because of the mental illness that they're out there.

[00:20:30] Sharon Black: That's right.

[00:20:48] Speaker 1: And and yet uh uh there's this hesitancy to to force them into a a situation that presumably will help them improve.

[00:21:06] Sharon Black: I want to respond to a couple of things that Dr. Carlton mentioned. Um, in terms of the 30 to 40% of people who are homeless having severe mental illness, um, that does not include people that have addiction only, but it does include those that have severe illnesses and also have addiction. If you include if you include people that um are addicted to substances like ice, which has become so epidemic in our community, the number, the percentage of homeless people in my experience goes upwards of 80%. There are very few people that are homeless purely because of hard luck. Usually something going on.

[00:22:00] Speaker 1: So what I I call a a street person, which I think of as as the homeless other than than the groups living on the beaches, that high percentage are either mentally ill or uh abusing drugs.

[00:22:19] Sharon Black: Or both.

[00:22:37] Speaker 1: Or both. Uh let's go to a call. First Steve from Eva Beach. Good morning Steve.

[00:22:55] Speaker Steve: Yeah, good morning. You know, I listen to your show last Sunday also, and uh there has been talk about uh the laws and involuntary treatment and and I guess treatment in general. Right. And I'd like to bring up a point maybe that uh well, let's take a look at like what's below all that, you know, why people don't want treatment in the first place. Uh, I think that the psychiatric treatment, or so-called treatment, uh is pretty brutal. And uh people maybe don't even take a look at what that consists of these days.

[00:24:07] Speaker 1: What do what do you have in mind? Can you describe it to me because I I really don't know.

[00:24:25] Speaker Steve: Oh, okay. Well, there uh there are shock treatment for one. That's big money maker for them. And uh you know, people don't look at what shock treatment is and what it consists of. And uh their treatment that I can see, drugs and shock treatment, is pretty much uh turning people into vegetables. And uh it's no better off for them. So, like you take a guy, right? You say he's mentally ill, hit him on the side of the head with a hammer and you know, call that a treatment and a cure because now he's no longer uh a danger to himself or society.

[00:25:20] Speaker 1: Okay. Steve, stay on the line. I want to come back to you. But Barry Carlton, are you still there on on line six? Barry Carlton, are you there?

[00:25:56] Barry Carlton: Yes.

[00:26:14] Speaker 1: Um you're there in in the hospital um providing treatment at at that level. What's your reaction to what you're hearing from Steve?

[00:26:32] Barry Carlton: Yeah actually before I um get I'll answer that but I want to say one thing in response to something that um uh Sharon said. That there is a very real problem in our laws that it is relatively simple for um people who are homeless and who act in a criminal fashion to um be incarcerated, which is unfortunate. And they as Sharon says, they don't belong there. However, the way the law reads, in order for somebody properly, in order for somebody to be um tried if they are arrested, they need to be able to understand the proceedings. That's called fitness. So that the judges are able in order to restore fitness, to order medication in a much simpler and less um complicated fashion than um than um what happens if someone enters into a hospital civilly.

[00:27:26] Barry Carlton: The criteria for being incarcerated into jail, that is what you have to do is a lot less dramatic than um what happens to get into a hospital, for example, or into treatment. Also the um the other anomaly is that if someone is charged with a crime and they can't bail themselves out, they can stay uh over in in in incarcerated until the acuity is over, whereas they could not on a hospital level of care. So there's a bunch of anomalies in our in the laws that are really kind of peculiar, which um which I think causes problems all around. And obviously these people don't belong in jails. I mean, the 30% of the population, it has been estimated that close to 30% of the population in our correctional settings have mental illness.

[00:28:02] Barry Carlton: Now, getting back to Steve's question, I think that in the early um 60s and in the late 50s, when psychiatric medications were first um developed, the um amount of medication that was being used and the experience of the medication was for some people to quote, as he said, turn them into vegetables. That is the side effects, the sedation, the muscle stiffness, and some of the difficulties with the medicines in large doses, did create admittedly some difficulties. But medicine advances and the medicines have become cleaner, that is they have fewer side effects. They um are used at this point mostly in much lower doses as we learn more, um so and as we learn more about how they act. Um and that's also important, that the medicines for controlling thinking, when you first give them, the effect is to help people feel more calm and more sedated.

[00:28:39] Barry Carlton: It takes at least two weeks to change thinking. Um so that currently with that knowledge, uh lower doses are being used, so there is less of and again, to use Steve's words, a club-like effect. Again, the the issue of ECT and um That's the shock treatment. Shock treatment has always been a problem um in the press. And again, if you look at the history of medicine, um there have always, you know, leeches were used to do all sorts of things in the 1700s. So medicine does indeed march on. Now, how ECT got discovered was that in the hospitals of the 18th 19th um century, there was a mixture of people with psychiatric illness and neurologic illness.

[00:29:33] Barry Carlton: And it was discovered that there was a certain group of people who acted odd, it was observed, that a certain group of people who acted odd and dangerous, if they had a seizure, they got better and no one quite knew why. Then that became uh able with the march of technology, it was possible for certain behaviors uh to be able to induce seizures. Uh correct. As the march of technology went on, it became possible for seizures to be electrically induced. And then some people with some bits of be with some problematic behaviors, usually severe suicidality or aggressivity, did indeed get better. Now, when a treatment is the only treatment available, admittedly it perhaps got overused in the 20s and the 30s up until the 50s. Currently, in the islands, there is very little ECT.

[00:30:45] Barry Carlton: Nationally, um that it's the indications are real as well as here, we do do some ECT at Queen's. Uh the indications are really quite precise and as a matter of fact, for severe depressions with for people who are overwhelmingly depressed, who can't eat, who are uh feel compelled to kill themselves or can't get out of bed and are preoccupied with very morbid themes, um ECT can very rapidly um make them feel very much better without any real adverse effects.

[00:31:03] Speaker 1: Okay. Let me see if if Dr. Margaret Copy has has similar thoughts about that or or different thoughts and then I'll come back to Steve and Eva Beach.

[00:31:21] Sharon Black: Yeah, Steve, I'm really glad that you called to ask um and make your comment about treatment being brutal. Um this is uh something that's been put out especially in in um movies and uh even this in this past year there have been several movies that showed psychiatric wards where everybody was drooling and incoherent. Um I agree with Dr. Carlton that medication doses have decreased so dramatically that um the side effects are much much easier to take and also that shock treatment is very, very seldom used compared to in the past, particularly in the people with schizophrenia, which is the main group of mentally ill street people that um Randy's talking about. Um shock treatment doesn't help them much and isn't used.

[00:32:34] Sharon Black: is in I sing was for

[00:32:52] Speaker 1: But as he know I'm using 25 milligrams.

[00:33:10] Sharon Black: I agree with that, you know, your impression that medication causes side effects that are pretty hard to take and we always have to balance what's worse, the side effects and the risks, or the side effects and the risks of having the illness and I want to say that I believe that living on the street is far more brutal than the treatment for mental illness as is prison and we currently find up to 20% of people in prison have severe mental illness.

[00:33:28] Speaker 1: Steve, does that answer your question?

[00:33:46] Speaker Steve: Uh well, it wasn't really a question. I'm still pretty much uh convinced about the the treatment of psychiatry. Uh

[00:34:04] Speaker 1: Are are you convinced because you think that that the actual treatments being used are are more harsh than what's being described by Barry and Margaret, or what's the basis for your disagreement? Because I'm I'm I'm ignorant in this area and as I listen to them, it sounds to me like like it isn't a club against the side of the head.

[00:34:22] Speaker Steve: Well, okay. uh you know, you have to take a look at the results and uh the statistics of their cures and uh what it actually does to people. Like I say, why is there a resistance to uh involuntary treatment or uh uh You're saying it the hospitals why the laws right. You're saying that's You're saying that's rational that that that they they don't want to go through the treatment because the treatment is brutal. Yeah. Uh and you know, I don't believe that our legislatures uh would make laws uh just off the top of their head where there's no problem. They must have addressed this that, hey yes, there is some problems in this area.

[00:34:59] Speaker 1: Okay. And uh you know, they don't they don't make a a a law unless there is a problem. That's what I'm saying. Okay. Steve, as far as like the drugs, excuse me, let me let me continue a little bit more. Uh you know, one of their their major drugs is Prozac. Right. Okay. Now, there are currently on file with the FDA over 28,000 complaints about the drug. And it's growing. It's a growing list. It's it's continuing every more so than any other drug in the history of the FDA. Okay. Let me ask Margaret Copy about that. Margaret, I I think even I have heard of Prozac and I think everybody realizes that it's it's controversial. Uh what's your reaction to what Steve's saying?

[00:35:53] Sharon Black: Um, Prozac has gotten a lot of bad press and consequently, there've been quite a number of studies looking at it and it has not been found that Prozac um has all the problems that have that have been put out in the in the in the press. Um, basically, it was thought that Prozac might actually cause people to be more suicidal or more aggressive and that hasn't Prozac is not the drug that is going to help them. I mean, some of them have depression and you can use Prozac, but Okay. Steve, I I appreciate your call. We're going to have to move on, but I sure appreciate you calling. It's the price of Paradise Radio show.

[00:36:29] Speaker 1: We're talking about mentally ill street people. Uh what should society be doing differently, if anything, about uh their situation? If you'd like to ask a question or make a comment, just call us. like the show in its entirety tonight at 8 o'clock on KIFO, that's 1380 AM, the entire show will be replay. The number to call again is 955-8821. We have a couple of people on the line whose names I recognize. First Randy Hack who was um uh one of the people that we talked to last week. Uh Randy is the executive director of United Self-Help and himself a consumer of um of uh of mental health services. Randy, are you there?

[00:37:05] Randall Roth: Yes, I am.

[00:37:23] Speaker 1: What do you have for us this week?

[00:37:41] Randall Roth: Well,

[00:38:00] Speaker 1: I was just reflecting on um what was said this morning and uh being in the midst of an area, working in an area where there's a lot of homeless mentally ill people. I just know there isn't enough service available to help people and uh especially um supportive housing and uh engaging people so that they don't have to be on the streets. And it takes a lot of patience and persistence to to help people who are homeless and mentally ill because people are afraid, and uh in my work area, there's a program called caravan, which sends vans out with nurses and outreach workers to help people who are homeless and maybe offer them a sandwich or something like that, but uh a lot more of all kinds of services are needed. And uh with the state's financial situation being the way it is uh and the cutbacks and entitlements, things are not going to get any better.

[00:38:51] Speaker 2: Okay. Well, and I I think as I'm hearing what you're saying, Randy, it it sounds a lot like uh some of the themes in Margaret's article in the paper this morning, Margaret.

[00:39:43] Margaret Copi: Randy's absolutely right. Services don't just include drugs. Services include reaching out to people who may not understand that they have any illness, and making friends with them, and offering the to help them in any way that they feel they need at the moment. And then once you help them over time, they learn to trust you and you can begin to talk about what they're experiencing, that it may be that they have an illness and begin to offer them medication as treatment. But also, to one of the problems with the lack of resources is the lack of uh supportive housing. Supportive housing is very critical in the treatment of people that are homeless who do have severe mental illnesses. And we've discovered all over the country providers that help people that are homeless who have mental illnesses. We've discovered that um they do well, that they will stay in housing, that they haven't chosen to be homeless. But we have to offer help, a special kind of housing, supportive housing, where they're staff to help them get through the days.

[00:40:35] Speaker 2: As I understand it, supportive housing includes um two notions that I think would be a little bit controversial. One, we've talked about that the people living there aren't forced to take their medication, it's it's up to them. And the other, as I understand it, is that if they have general assistance or some other cash benefit, um that that they're allowed to to keep that and spend that as they want, as opposed to turning it over to whomever is that's running the housing. Is is that correct, Margaret?

[00:41:27] Margaret Copi: Supportive housing needs to be funded. Um usually people's benefits will they'll they'll need to spend some of that on their housing, but um the federal standard when it's federal housing is 30% of income. So, for example, if someone here has $400 in GA, then they'd spend a third of that on their rent if we had federal subsidies here.

[00:42:19] Speaker 2: Okay, but there are people as I understand it who feel that a condition of the housing, in addition to the medication, is that that they should turn over the money and the money be managed for them. And as I understand it, you're feeling that that that that that's not the way it should be, that they should manage their own money even even when they're suffering from mental illness.

[00:43:10] Margaret Copi: Um there's a mechanism for taking away people's right to control their own money if they've shown that they're not competent to handle it. For example, some people, because of their symptoms, will as soon as they get their money, they'll give it all away, or they'll tear it up, or they'll spend it on things that um don't really meet their survival needs. So, when people have demonstrated that, um then it can be arranged for them to have a representative payee to manage their money for them. But um just because they have mental illness doesn't always mean that they can't manage their money and as much as possible, people should be able to um have as much freedom as they can.

[00:44:02] Speaker 2: Okay. We also have on on the line again Sharon Black, who's the coordinator of the Honolulu Police Department's Project Outreach Outreach. Sharon?

[00:44:54] Sharon Black: Hi. Uh I believe you had a a comment based on something that uh Barry Carlton said a little bit earlier. Yeah. I think that, you know, being on the streets directly every day, and uh having the kind of cases that I have, I feel that a lot of times over 600 cases that we brought into uh the emergency rooms because of uh imminent danger to self or others have shown imminent danger to others because of their illness. By arresting these individuals, many a times, the courts will not even prosecute for the mere fact that they're not uh in the right state of mind. So, what happens is they they come right back out and there's no treatment, and I think that's where it's a really strong point for us to look at. The other thing is dual diagnosis, which is really important, because many of these individuals with mental illness are self medicating either through alcohol or through drugs or both, and that's extremely important. And as uh Dr. Carlton stated, you know, usually just to stabilize these individuals it takes at least 2 weeks, and unfortunately, I think in many of the cases that we found that we brought in, come out well before that time. I mean, sometimes within a day, and then we see, you know, tragic results. You know, as much as I realize they're the majority by far are not a danger to self or others and are are just, you know, dealing with their symptoms and so forth, there are those that are, and that's not to be downplayed because even if it's just one individual that goes out, you know, and gets on a bus and assaults an elderly lady, uh you know, because of the illness itself, you know, that's something to take extremely seriously. And I think that the communities are really starting to become very aware because more of these situations are coming out with less adequate treatment and the amount of treatment, you're going to have more assaults, you're going to have more uh dangerousness to themselves or others. And I think that that's something that we really need to look at instead of saying, well, let's just put them in jail, because in jail they're safe. In jail, you know, these these bars and a four wall, there's no communication, there's no, I think it makes the illness worse. I don't see how that helps at all.

[00:46:38] Speaker 2: Okay. Sharon, thank you. Appreciate your calling back and and sharing that. Let's let's go to Graden in Honolulu. Good morning, Graden.

[00:47:30] Speaker Graden: Good morning.

[00:48:21] Speaker 2: You're on the air.

[00:49:13] Speaker Graden: Okay. Uh well, I I just tuned in late, uh but I heard you talking about treatment for depression and uh I was treated for depression with anti-depressant drugs, Serzone and Zoloft, and the side effects were too negative uh to cope with. Uh they made me more depressed. And in desperation, I looked for uh treatment through acupuncture, and um I went to an herbalist, and instead of acupuncture, he gave me herbs and uh they've worked without side effects. So, um there's alternatives and uh that's one that worked for me.

[00:50:05] Speaker 2: Okay. Thank you for your call. Margaret, any any comment on that?

[00:50:57] Margaret Copi: Yeah. There are a lot of people who cannot tolerate the psychiatric medication, and I'm one who believes that whatever works with the least amount of problems is what what you should do, and I'm happy that you were able to find something that helped you.

[00:51:49] Speaker 2: Okay. Let's go to Dan in Honolulu. Good morning, Dan.

[00:52:40] Speaker Dan: Oh yes, hello. Um my question is uh well first I have a comment that the addresses the uh the spectrum of mental illness that I hear talked about. Uh it's I think it's easy to lump them all together and group them as a single group, but actually it's quite a diverse group that I I think the uh everybody would agree with that the uh the expert panel. My question is, um to what extent does that group consist of people with personality disorders rather than uh uh medical mental illnesses, for which the treatments are very poor and that there's a lot of behavioral issues, and that uh there's a lot of recidivism also, that these people are in in housing and then they're back again. They often have dual diagnoses as well with drug uh drug and alcohol abuse.

[00:53:32] Speaker 2: That That's a I think that's a really good question. Margaret, I've wondered in my own mind whether it's a a black or white, you know, you're either mentally ill or you're not, or whether there isn't some grayness in there and and some people who have some problems, but it's not necessarily mental illness.

[00:54:24] Speaker Dan: We think we call it mental illness, but uh But it's something else. It it's actually Well, it it's part of the spectrum. It's actually I'm addressing it specifically because it's the part of the spectrum that medical treatment is is sorely inadequate for. And that there's a fairly high percentage of street people I think that actually have this kind of diagnosis, and who uh who if you did give them a uh liberal housing uh uh uh benefit, and ability to manage their own money, they would probably uh uh abuse that that uh that privilege because that's more of a lifestyle for them.

[00:55:16] Speaker 2: Okay. You know, Margaret and and as I I passed Dan's question on to you, when I talk to a lot of people getting ready for this show, whether it's a perception, misperception, I'm not sure how to describe it, but I think there is a feeling that there is a lot of abuse of the system right now, and I think that's a a part of what what Dan is commenting on. What's your reaction to that?

[00:56:08] Margaret Copi: Well, there are a lot of parts to the questions that both you and Dan had. Um regarding personality disorders, yes, that's a a part of the range of mental illnesses. Um but also, in response to part of your question, there is a difference between a person with a mental illness and one without a mental illness. Um but there's a continuum um between somebody who has enough symptoms to know for us to know that they have a mental illness, between one who feel for example, one who feels a little bit blue, doesn't have a major depression, doesn't require medication, even someone who feels very, very sad as when one of their loved ones dies, they still don't have a major depression requiring medication. Um somebody who feels a little confused or sees um uh monsters in the shadows doesn't mean they have schizophrenia. Um just as somebody who has a stomach ache doesn't necessarily have belly cancer. Um everybody has symptoms that go up and down from day to day, but not everybody has um has an actual biological disorder. Um regarding the personality disorders that you you're right, that's a very um thorny area within psychiatry, it's difficult to treat personality disorders. They don't respond particularly to medications. Um they do respond to psychotherapy. Um but it's sometimes difficult to engage them in psychotherapy because most of them don't uh have the ability to trust anyone. Most of the people with personality disorders got that way because they were tormented as children. Um child abuse that's more in the category of torture. Um so I have a lot of sympathy for them. But as adults they do have behavior that's very hard to take and and get people quite mad at them. Um as far as how many of the mentally ill homeless have personality disorders, I think it's a fairly small number. The preponderance of street people with mental illness are people that have schizophrenia, and it's very important not to label them as having a personality disorder because people with personality disorders um are basically rejected and seen as not worthy of help. Because we really don't partially How put this. They're seen as not being very amenable to help and also they're so um provocative to others that people tend to dislike them and reject them. A person would call them a jerk. Right. So a jerk doesn't deserve any kind of help. Exactly. Yeah. Okay. Dan, does that respond to your comment? Uh yeah, it does. Okay, thank you very much. Thank you. We go to Ruth in Kailua. Good morning, Ruth. Yes, good morning. Please, my call is about some of those providing assistance to the mentally ill. As to Sharon Black, I know her, the root a serpent of law, and that perfidious is a serpent of human rights. As to Dr. Carlton, it is a well publicly known fact how poor his treatment of the mentally ill can be. In addition, he's a weasel who listens more to phony lawmen than to the patients. Ruth, Thank you. Thank you for your call. Well, we're going to have to give some people a chance to respond to that. Uh Dr. Barry Carlton, are you there on the line? Yeah. I apologize. One of my jobs here is to try to keep the conversation real constructive and and I didn't do a very good job there. Um any thoughts you want to share on anything that you've been listening to over the last uh 20 minutes or so since we've heard from you? Yeah, I think the um um the housing issue needs to be going be going back to and the idea that people take advantage of the housing. I think often um whether or not people with psychiatric illness when they run into trouble with other, they tend to run into trouble with other people because they're una they don't know how to talk with them. They don't know how to interact with them, they can get too close to them and that's how fights start and that's how criminality begins. And if they have a place where they are reasonably safe, you will tend to decrease the criminality, you will tend to decrease uh the criminality and um and make it possible for them to live relatively um relatively comfortably. That with the the question about the personality uh disorders, there are unfortunately people with personality disorders um on the one hand it's the idea that they are quote not ill, end of quote. Yet there will be a few people with personality disorders whose ability to cope because of the things that have happened to them as they were growing up, they become very odd people. So again, like people with schizophrenia, they find it very difficult to cope with things such as um work or providing housing for themselves. And as Margaret said, make people um make people um very angry. Okay. It it it it are we really just talking about resources here or or are there resources out there but they're being missupplied or or do we just need more resources in order to provide the kind of supportive housing that you and Margaret have talked about? I think that um Hawaii become I think the problem there is frankly the nature of Hawaii. For example, in in Philadelphia, where there was a great deal of derelict housing, there was a Robert Wood Johnson grant that uh turned uh derelict housing into apartments for the homeless mentally ill and each um person had their own apartment and the rate of criminality amongst those people diminished, the rate of admission to hospitals plummeted and the people's ability to take care of themselves um with or without medication went up remarkably. Unfortunately, Hawaii doesn't have that um sort of um doesn't have that level of derelict housing. Um so the the I think the the resources that would be required are fearfully expensive, and I has to do with whether or not we as a society wish to pay for it. Okay. Barry, thank you. I really appreciate your being with us this morning. Uh, we're going to go to Ivan in Aina Haina and then if if Sharon is still online, we we'll go to her before the hour is up. Let's go to Ivan in Aina Haina. Good morning. Good morning. Just a very quick uh question. What is personality disorder? Why is that different from mental illness? I I just a matter of terms, but I do not understand the conversation very much. I think that's a good question. Let me ask Margaret copy. Okay, thank you Ivan. Personality disorder is a type of mental illness and it's characterized by a very rigid set of responses to the world around the person. Um they can't adapt well, they're not flexible, so that if a person with a personality disorder feels that everyone is out to get them and is always doing something bad to them, no matter how much you try to help them, they always feel like you're against them and they lash out at you. And unfortunately, it it I think you said that medication doesn't help them the way it does somebody with a different type of mental illness. That's right. Okay. Um Sharon uh Black, are you still there online, too? Yes, I am. Uh do you have any parting thoughts? We're getting close to the end of the show, anything you'd like to say before we finish up? I feel very strongly that, you know, each part of the system has to work. The community has to demand that it works for the safety of all, for the individuals who need the help and for the individuals who don't understand that they need the help. Um you know, it's one thing for the police to pick up these individuals and bring them in for an evaluation. Then the next piece is for those individuals to hopefully get the treatment that they need and in the length of time that they need it so they can stabilize. And then there's the other pieces that have to come in too. But I think what's happened is is much of the system has closed down and many of it some of the reason sound like they're based on financial, you know, because of the cost, but in actuality, it's costing the system 10 times more to continuously do crisis intervention as it would be to do a a proactive, interventive approach. And until we change our attitude and make sure that each and every piece of the system works, I think that's going to be about the only way that there's really going to be results in getting these individuals help. Okay. Sharon, thank you very much. We really appreciate your being with us this morning. Thank you. Margaret, before the show, I was asking you if if maybe we don't need a paradigm shift. Just do things.

[00:57:00] Randall Roth: differently than we've been doing them and you commented that you feel that that you're you're doing something differently and you're trying to talk others into coming along. Describe that to us.

[00:57:21] Margaret Copi: I think that the major difference between what I do and what has traditionally been done is that I don't expect people that are mentally ill who are on the street to come into me for help. The way the community mental health system is set up, we have clinics and people have to walk in and be able to say, hi, I'm ill, I need help, will you treat me? And that's not realistic. Because one of the major elements of the illness is a lack of awareness of their illness. They don't come in for help. And indeed, if you approach them and ask them too early if they'd be interested in treatment for their illness, they will run from you.

[00:57:43] Margaret Copi: So it's very important to establish a relationship on a personal basis one at a time and with a generosity of spirit in order to help people who really need it.

[00:58:04] Randall Roth: You you make a friend and then eventually maybe that's a patient?

[00:58:26] Margaret Copi: That's right.

[00:58:47] Randall Roth: Okay. Well, I guess we have time for one more call and Mary from Kona has been waiting patiently. So let's go to Mary in Kona. Good morning.

[00:59:09] Speaker Mary: Good morning. I I'm calling. I have a son who's mentally ill. I also have worked extensively with mental illness on the mainland and was director of a program for the mentally ill, and so I'm very familiar with the whole gamut of what we're talking, what is being discussed today. What, and it's again, very frustrating. What's prompting my call is I wonder if the resources that are exploring this right now, if there's a way that a tax credit could be given to persons who provide housing. Is that is that something that's been explored in the state of Hawaii?

[00:59:31] Randall Roth: Margaret Cobby.

[00:59:52] Margaret Copi: Um, there's I think the banks are required to uh, fund or loan money for a certain amount of public interest usage, such as supportive housing. But as far as individual families, for example, having a tax credit for housing their own mentally ill relatives or the providers of supportive housing, I don't think that exists right now, but it's a good idea.

[01:00:14] Speaker Mary: Well, in other words, for us to really look at this problem, it shouldn't really be the family as much as anyone who could provide housing for this population. Perhaps if we gave some tax incentive there would be more social consciousness about that.

[01:00:35] Margaret Copi: It can't hurt, it might help. I think we should try everything.

[01:00:57] Randall Roth: Tax credits, radio shows, you know, whatever we can do. Okay. Mary, thank you for your call. Um, Margaret, we've just got a minute or so left. Um, there's an awful lot that we haven't gotten to. Um, any any last thoughts that you'd like to share with our audience?

[01:01:40] Margaret Copi: Um, I think that there's a a sense by a lot of people that we've got to get these people into a hospital and they say, these people and put them into a group and say, all these people need to be out of sight and in the hospital. And as Dr. Carlton said, hospitals these days, um, don't keep people very long. You stabilize them briefly and then discharge them. Um, so hospital is not available. It's not an available option right now. But we have to have a place indoors for people to live and be safe. And then when they're feeling more secure, we're going to be more successful in treating them, and many of them can have fairly normal lives with relationships and a meaningful activity and that should be our goal.

[01:02:02] Randall Roth: And I guess in addition to not having the ability to to treat them long-term in a hospital, we don't have many long-term treatment facilities out there.

[01:02:23] Margaret Copi: Right.

[01:02:45] Randall Roth: Okay. Well, we've we've run out of time. I want to thank my guest this morning, Dr. Margaret Cobby, who is a psychiatrist with the Calihi Palama Health Center's health care for the homeless project, and also the new Beretania Street Safe Haven residence for homeless and mentally ill persons. Also, Dr. Barry Carlton, who's an associate professor of psychiatry at the University of Hawaii School of Medicine, and director of Queen's counseling and clinical services. We also had Sharon Black, who is the coordinator of the Honolulu police department's project outreach. Uh, the director of operations for the price of paradise in Hawaii Public Radio is Jeff Ilardi. Our producer is Suzy Roth. Uh, usually we we run out of time and I'm told that we actually have a minute to go. Boy Margaret, you just witnessed that a first here. Uh, go ahead and take 20 seconds to give us a little bit more wisdom as I'm sitting here with a red face.

[01:03:28] Margaret Copi: Well, one question people ask me is what should I do when I come across a panhandler who wants money? And I'll tell you what I do. I carry around health food candy bars and I give small food items, clean socks. Little things that can help people are are much better than giving cash when you're in that situation.

[01:03:50] Randall Roth: I like that. Remember folks, when you go to the park or Fort Street Mall or whatever, clean socks, a healthy candy bar, right? A granola bar or something. Thanks a lot. You've been listening to Pop Radio. I'm Randy Roth. Aloha.