Thursday, September 12, 2013

Fallen Arches

I am very grateful to those of you who by reading my blog help me to push back my delusions of utility.  By actually having some readers, I cannot retreat into my customary, if necessary stance of entirely self-directed ruminations.

Sometimes the very same things happen at the extremes of our ministry: Instances occur so far from the normal run of things that it strikes me how providential it is that I have you to tell about them.  If they were mine alone, I might as well write them on black paper with India ink.

A woman we’ll call Ann called me two days ago looking for her mail and I asked her why she didn’t get it when she came home.   “I got thrown out for taking a shower at the wrong time,” she said.   Now I have grown to hate the innocent; this is my great gift from the Franciscan Order of Penitents, so I knew she was guilty.  After a circumambulation in which she addressed all my wife’s imagined sins, (consisting solely of Ann's unmet needs) I decided it would be better to keep Ann at a distance, so I offered her an ongoing opportunity to call me to see if her check had arrived.

Having been offered an inch, she appeared at the door, demanding her mile, forcing her way into the house and offering to beat my wife, call the police and alert the media if we didn’t produce her check.

Now we have a deal with the City courtesy of Federal Judge Nakazato, wherein we can “ignore” R2b zoning on Sunday morning because we’re “religious.”  This means we can be open to the public like a Mailboxes USA only on Sunday before Noon.  Nevertheless, we give the homeless five other chances each week to check their mail at the Civic Center, conveniently while eating our tasty food.

So Ann terrified Leia, not just with threats of violence, but with the very real possibility that the neighbors, ever mindful of property values, would file a justified complaint about a loud fight during the week “with the public.”

When I got back from Seal Beach on an errand, Leal was understandably furious – and I felt terrible.  My wife had been threatened, almost beat, in my absence and I had failed to protect her.  I was mortified.  And this wasn’t the first time…

At the root of all this tragedy, especially for Ann, is the atavistic disregard with which the OC prioritizes the mentally-ill.  One day I watched a Mental Health outreach worker struggling to decipher his notes.  “They’re making us tear off the unused goldenrod copy from old forms and write on the back.  I guess we can’t afford white notepads.”  A call to NAMI, the National Association for the Mentally Ill in Orange County, confirmed that patients referred to the local MHA, the Mental Health Association, must have been inpatients within the last six month or the referral is refused.

Imagine if you could only visit your doctor under the same terms.  I had a tonsillectomy in 1954 and an appendectomy in 1973, so I would have been locked out of my Doctor’s office for the last forty years!  In addition, there is a marked difference in the severity and persistence of disorders leading to inpatient mental hospitalization and physical surgery.  Many regular hospitalizations, such as mine, completely resolve the underlying condition in a week or less.  Not so with psych admissions.  Now most mental health patients never need hospitalization, because lots of things can go wrong in a persons life, terribly wrong, without incapacitating them completely.  When a person is hospitalized on a publicly funded psych ward, there’s a fair chance that they’ll be very sick for a very long time. 

What this means is the entire Mental Health Association apparatus is focused entirely on those people they are least able to help.  When I worked administrative support in the emergency room of a Community Mental Health Center in the Seventies, the inpatient psych ward therein hired only two types of employees: psychiatric technicians or (nurses with equivalent training) and psychiatrists.  That is because the treatment for inpatient level mental disorders is almost entirely psycho-pharmaceutical; among two hundred employees we had more janitors than Social Workers, no “case managers” and only one Psychologist for administering psychometric tests offered in evidence in our in-house courtroom.

Since this policy change, that is, the county’s idea of treating only the “untreatable,” carried with it no corresponding debacle among the staff, I have it upon the good authority of the torpor which is ever-present hallmark of governance in the OC, that I can be pretty certain they’re all “outpatient” type workers from before the change.

Only in Government Psychiatric Care can you find the equivalent of Candy-Stripers in the operating room.  And when the patient is homeless, it likely the person holding the “scalpel” will be merely another patient: Like the MHA’s “Peer Treatment” program where the blind lead the blind!  This community is the connection Ann was depending upon to inspire and motivate her to take her meds.  The meds that blunt her affect, steal her sex-drive, make it impossible not to gain weight and leave her in a fog only anger and street drugs can cut through.  The meds likely do the same things to the “community partners” and yet one would presume they take them since they have no other professional qualification as therapists.  They are the living examples offered to Ann as role models.  Perhaps if we paid Ann a salary and supervised her behavior 40 hours a week she could concoct some other factors besides cash and surveillance to make the uncompensated and otherwise ignored street client comply and take their meds.  I know I can’t.

More than anything, it is the wholesale abrogation of responsibility to inpatients that marks both the genesis of homelessness and the terrible sin that is at the core of community psychiatry.  From the untested, totally unwise relocation of state hospital patients into community mental health centers to the ingrown horror of blaming patients for not getting well, it falls to us to pick up the pieces, or, as in Leia’s case with Ann, get threatened with them.

About three months ago, one of the “staff” at the MHA Day Center conceived of a solution to referrals that’s almost as insane, and I use that word carefully, as the American Psychiatric Association’s complicity in the disestablishment of the State Hospital system.  The MHA “staff” began to advise the patients they referred here to conceal their past:  “Don’t tell the Dwight’s House (their unique appellation for the OC Catholic Worker) you were an inpatient, and never admit you’re on meds!  And don’t say we referred you or they’ll know!”  Needless to say it was immediately apparent from the fact that the MHA “staff” had failed to consider the requirement for an alternate  “cover story,” that every guest who exclusively and quite dumbly refused to in any way share where they’d been the last few months was one of theirs.

I called Mark Smith, the Director of MHA’s Inpatient Services, and told him as long as this formal deception was MHA policy we would be admitting no one.  The only times we had ever been assaulted was by MHA referrals, and now that they were hiding among the homeless we simply would refuse to accept anybody.  He immediately insisted that this would stop and it did – the “peer helpers” at the MHA hadn’t told him either!  Implementing a policy of lying to the only women’s emergency shelter in Orange County is likely indicative of the stellar quality of therapy that failed Ann so miserably, as well as the other homeless.  Every altercation we’ve had in the past five years has been with an un-medicated mentally-ill client who was either declined mental-health treatment because they hadn’t been an inpatient or a former inpatient the MHA couldn’t inspire to stay on their meds.  Is it any wonder that the first thing that occurred to them was to lie about it?

And who could blame them?  For at the top of their vocational food chain we see modeled for their inspiration the exact same behavior: lying and blaming someone else.  Only psychiatrists could guide an entire country in allowing police and the public to blame mental patients exited from State Hospitals (the original homeless) for not being in a hospital, locked away from those of us who will never understand why they “choose” to be homeless.

A nurse I think the world of told me a story about his first month on the job that is uniquely representative for what we’ve done to our poor:  As a young nursing student, he was easily the largest, toughest student ever, 6’2” 180 lbs., so they short-circuited his education to give him “work experience” on the psych ward of a local hospital.  There was a lot of work to be done “winding down” because either the hospital or perhaps just the psych ward was being decommissioned and the patients were understandably agitated.  He performed like a natural in those few weeks so I’d like to think that’s why this young, unsuspecting hulk was given the “last job.”  In spite of the best efforts of the unit’s social-work staff, whatever that looked like, there were seven patients who, on the last day, had not been out-placed, either because no other hospital wanted the trouble, or because their insurance was inadequate.

Now this last job started out with a great deal of fanfare – everyone, even the locked ward wackjobs, were going on a field trip to McDonalds.  My friend was told once everyone had prayed over and then become enraptured at the prospect of a piping hot, actually fresh Happy Meal, he was to bring back just the van, placing the keys in the accounting office, and then go home.  Now he was used to a lot of short shifts and irregular turnovers within the psych ward, so he had assumed, and, this being very important to our understanding of community psychiatry, had not been dissuaded, from assuming that someone else would get the keys and take those seven patients to their new hospital.  The odd nature of the field trip, the lack of supervision, and the concealment of facts, however, ate away at him, and even though he no longer worked for MidCentral Regional Medical Center, he decided to go for a burger exactly one week after his last day and the last job.

Five of the seven inpatients were still there, begging from the customers, sleeping at night behind the dumpster, the meeker ones foraging through the trash for the fulsome remnants of plates served up to spoiled swells offended that their parents had “forced” them to dine at MickeyD’s.  There was plenty to eat, the immense sea of concrete kept them warm at night, and odd behavior and the lack of showers generally kept the odd good Samaritan at bay.  The two patients missing from the original half-dozen had strayed from the haven of the 24 hour eatery and interacted with frightened citizens denied the context of the Golden Arches under which everything could be assumed to be well in hand.

Somebody once said that there is a tide in the affairs of men, which, taken at the crest, leads on to glory.  No one has heretofore used that hopeful snippet in reverse, so let me be the first to tell you about not the crest, but the much more interesting environment, of the troughs.  Sometimes we have to wait for the seed planted deep within an extraordinary individual to await their accumulation of maturity and capital for the flowering to take place; Christ’s sermon about the seeds sown in adversity was never so prescient. 

This nurse is now founder and director of the most amazing and innovative homeless shelter I’ve ever seen.  Some other time I’ll tell you how a bunch of altruistic MBA students followed that nurse and managed to create a truly Copernican breakthrough in homeless services.  Now it’s virtually impossible to have as a key corporate virtue humility, but they do.  By putting the client, or perhaps the clients’ kids first, and then humbly outsourcing everything someone else does better, they became overnight the most reliable, fastest growing provider in Orange County. 

Why non-profits should engage in capital formation is a great question and they have answered it – they needn’t unless the mission requires it.  Only a truly innovative MBA program could get an investment banker and a bunch of marketing and computer geniuses to forego creating something that lasts.  When these people say they hope to put themselves “out of business” they act like it.  If we truly believed in our 10-year plan to eliminate homelessness, why is everybody else putting a 50 year roof on their transitional shelter?

Because we all know deep down inside that the real disorder here is not homelessness, but the same rot Christ addressed in his greatest sermon and only commandment: “Who then is my neighbor?”

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