In a downtown Los Angeles parking lot, a stretch of asphalt tucked between gleaming hotels and the 110 freeway, a psychiatrist named Shayan Rab was seeing his third patient of the day, a man he knew only as Yoh.
Yoh lived in the underpass, his back pressed against the wall, a few feet from the rush of cars exiting the freeway. He made little effort to fend for himself, even to find food or water. When outreach workers dropped off supplies, he often let people walk away with them.
He could barely converse, absorbed by an inner world that he described in fragments: a journey to Eden, a supersonic train, a slab of concrete hanging in space.
But here he was, seated on a stool in the parking lot, talking to his psychiatrist. Two weeks earlier, Dr. Rab had persuaded Yoh to start an oral antipsychotic medication. Now the doctor wanted to go further.
“One thing that can make your life a little bit easier,” he said. “We have the same medication that comes as a monthly injection, so you only have to take it once. Is that something you’d be interested in? It’s better for you.”
“Yeah,” said Yoh, dreamily. His hair was matted, his ankles caked with dirt. He hadn’t slept well, he said, because he had been visited by a poltergeist.
“OK,” Dr. Rab said. “We’ll get that organized for you.” Yoh wandered back to his spot in the underpass, and the doctor climbed into his car, off to the next appointment. He was pleased. “That was a huge milestone,” he said.
Driving away, Dr. Rab passed tent after tent after tent. Around 75,000 people are homeless in Los Angeles County on any given night; in 2022, 2,374 of them died while homeless, mostly because they overdosed, or their hearts failed, or they were hit by cars. Officials are desperate to move them inside.
Street psychiatry offers a radical solution: that for the most acutely mentally ill, psychiatric medication given outdoors could be a critical step toward housing. Dr. Rab, a medical director of Los Angeles County’s Homeless Outreach & Mobile Engagement program, describes the system his team has built as an outdoor hospital, or sometimes as a “DoorDash for meds.”
Every weekday morning, 18 teams fan out across the county, making rounds with about 1,700 patients in tents and vehicles and alleyways. The teams try to persuade them to accept medication, sometimes in an injectable form that remains in the bloodstream for weeks. If clients say no, the teams return, sometimes for months, until they say yes; if they still refuse, the team can petition a court to order involuntary treatment.
This is a major departure for the field of psychiatry, which long discouraged clinicians from tracking down patients in the chaotic conditions where they live. It alarms patients’ rights activists, who say people living on the street may not be in a position to give consent. And critics question whether state resources should go to expensive curbside medical treatment when what people really need is housing.
But street psychiatrists say they are seeing transformations. When he gives presentations on the team’s work, Dr. Rab likes to display photographs of patients as his team first encountered them: inert, disheveled, barely visible in mounds of trash. And then, later, scrubbed clean, sitting on a bed in a group home.
“Please do not be discouraged — even after the fourth or fifth refusal, someone will accept it,” he told a packed room this spring, at the annual meeting of the American Psychiatric Association. “Wait for them to trust you enough to say yes.”
Dr. Rab thought Yoh could be one of those stories. Case workers had been visiting him in the underpass for five months, bringing him hamburgers and bottled water, gingerly building trust. It was leading up to this moment. Dr. Rab wanted to see what “this magical injection,” as he put it, would do.
‘Practice-based evidence’
It was 2018 when Dr. James Rodney Jones, then the medical director of a Los Angeles County mental health clinic on Skid Row, first injected a dose of long-acting antipsychotic medication into the arm of a homeless woman.
The woman was in her late 20s. Dr. Jones often saw her passed out in front of a 7-Eleven or arguing with security guards. She acknowledged “bipolar ups and downs” and alcoholism but refused medical appointments or shelter beds, instead trading sexual favors for a night’s stay in a tent. Stores complained that they were losing customers; every few weeks, someone worried enough about her to call paramedics.
Dr. Jones devised a plan: first, daily visits, bringing her bottled water and snacks. Then, as she became more trusting, he added an oral dose of the antipsychotic Zyprexa, which he told her would help her sleep. Several weeks later, at 10:30 one morning, Dr. Jones led her behind a telephone pole for privacy and gave her an injection of Zyprexa that would stay in her system for a full month.
Dr. Jones was taking a risk; he knew that. He asked a homeless friend to keep an eye on her, and for the rest of the day, he visited her every 90 minutes, to ensure that she was not too sedated. “I didn’t want to give her something that was going to leave her lying on the sidewalk, unresponsive,” he recalled.
County officials were “exquisitely sensitive about the legal liability of what I was doing,” said Dr. Jones, who retired from the county’s Department of Mental Health two years ago. Antipsychotic medications are powerful; in most patients, they rapidly quiet hallucinations and paranoia, but they can also have serious side effects, like sedation, which could be dangerous on the street.
“You can’t just go out and hand out medicine like that,” he recalled officials as saying. “Do they even have an open chart?”
He understood their caution. Prescribing psychiatric medication on the street often means working without a definitive diagnosis, medical records or laboratory tests. And because clinical trials are conducted in controlled settings, Dr. Jones said, there was no research to support using injectable antipsychotics in a homeless population.
But for Dr. Jones, this was “the perfect setup” for injections, which research suggests sharply reduce the risk of relapse. Six months after receiving her first shot, “less paranoid, less chaotic, less delusional,” the woman had moved into housing and was receiving disability benefits, he said. After that happened a few times, county officials took notice.
“Once we got them on” a long-acting injectable antipsychotic, “we could get them into housing, and once they were in housing, they would cost the county a lot less,” Dr. Jones said. While living on the street, acutely ill patients can cycle in and out of emergency departments scores or even hundreds of times a year, at a cost to the county of $6,000 per visit, county officials said. Over the course of a year, services for one person can add up to more than $1 million.
Dr. Curley Bonds, the chief medical officer of Los Angeles County’s Department of Mental Health, said his confidence had grown as he watched those patients move indoors after accepting treatment on the street. In a field preoccupied with evidence-based practices, he said, there is also room for “practice-based evidence.”
“It’s not like there’s a robust body of literature that you can look to to say, ‘Hey, this is safe, and we’ve done it here, and it’s OK,’” he said. “You’re going a lot on what you’ve seen work in the community.”
Over the years that followed, Dr. Jones’s Skid Row experiment has expanded into one of the largest street psychiatry efforts in the nation. Last year, the HOME team doubled in size and was allocated a budget of $43 million.
It deploys 223 full time staff members, including 10 psychiatrists, eight psychiatric nurse-practitioners and a clinical pharmacist. This summer, the team started mobile phlebotomy laboratories, which allow staff members to perform blood tests on the spot. Of the 1,919 people the team served last year, 22 percent ended the year housed; around 10 percent were treated involuntarily.
“There needs to be more dialogue about how it’s OK to break some of the rules,” said Dr. Bonds. “The rules don’t apply when someone has been on the street for 10 or 15 years and has difficulty engaging. You just can’t sit in your office waiting for those folks to show up for an appointment.”
Two John Does
Late on a Tuesday morning, Dr. Yelena Koldobskaya, the team’s other medical director, was crouched in front of a gas station on Firestone Boulevard in South Central Los Angeles. At her feet was Michael, a man in his mid-40s holding a grayish cheetah-print blanket. He was covered with grime and gave off a sour smell. He said he was waiting for his mail.
Michael had been a John Doe. The team had first spotted him weaving in and out of traffic; locals said he had been there for a decade or more. He rolled in dirt, perhaps to keep strangers away. At night, he returned to a particular spot in front of a strip mall, lay face down in the dirt, pulled the blanket over his head and slept.
The social worker assigned to him was Diego Gonzalez, fresh from a master’s program. Mr. Gonzalez began stopping by daily, with packets of chips; sometimes the man would throw them at him. Mr. Gonzalez kept coming. Weeks passed before the man softened enough to say his name was Michael.
The team had tried to place Michael in a motel, but it hadn’t gone well — he had urinated inside the room and wandered off. Michael’s options were narrowing when, in May, he agreed to start taking oral antipsychotics. That’s what she had come to ask about on this August morning. Were they working?
“Yeah, with brain stimulus,” Michael said. “Like the old Ritalin used to be — it’s like that.”
“I have another question for you about medicine,” she went on. “So the medicine sometimes comes in a version that you don’t have to take every day. Would that be OK?”
“Yeah,” he said softly. Then he began taking his pants off.
“Oh, Michael, you don’t have to do that,” she said. “Michael, can we put our pants back on?”
Dr. Koldobskaya tried to raise the subject of housing, but the productive part of the conversation had ended. “Cold to hot,” Michael said. “Hot to cold. Sea salt.” He asked for a cleaning system for his stomach. He complained about the green men who were a feature of his hallucinations.
Then he got up and shuffled away with the blanket over his head, wobbling toward six lanes of traffic.
Dr. Koldobskaya stood on the curb and winced as she watched him go.
“Poor guy,” she said. “He’s so, so symptomatic.”
But she noted, for the record, that he had given consent.
Talking them into it
Street teams have been expanding their role in homeless outreach for years, but there is little published research about what they do, so it is difficult to track negative outcomes, or say what works.
This absence of data, critics say, is a red flag in the field of psychiatry, whose history is marked by unproven treatments imposed on vulnerable people without their consent.
Samuel Jain, the senior attorney at Disability Rights California, said he had become aware of the rising use of injectable antipsychotics among homeless people this summer, when street physicians interviewed by the news site CalMatters declared it “an absolute game-changer.”
That claim, he said, “feeds the fiction that if you just take your meds, the societal problem will go away.” On an individual level, he worried about consent: Antipsychotics are “extremely powerful,” and patients must be fully informed of their risks and benefits, he said. Is that possible, he asked, in a doctor-patient relationship conducted on the sidewalk?
He also worried about coercion. Last summer, the Supreme Court decision in Grants Pass v. Johnson allowed local governments to enforce criminal penalties for living outdoors. With that threat looming, he asked, does a homeless person feel empowered to refuse an injection from a doctor sent by the county?
Some experts in mental health and homelessness have doubts as well.
Dr. Joel Braslow, who worked on a street team early in his career, said he had grown skeptical that antipsychotics should be used in the context of homelessness. They reduce symptoms, he said, but they may also leave people heavily sedated and more vulnerable on the street, and achieve little without other social supports — especially housing.
“Fifty years ago, psychiatrists would have found it inhumane to allow their patients to live without shelter,” said Dr. Braslow, a professor of psychiatry at the Columbia University Irving Medical Center.
Dr. Enrico Castillo, an associate professor of clinical psychiatry at U.C.L.A., said he worried that the hundreds of millions of dollars being used to provide street treatment would be better spent building housing. There is, he said, a strong base of evidence supporting “housing first,” in which individuals receive permanent housing with no strings attached, and treatment is offered thereafter; no such evidence exists for street psychiatry.
“It’s a lot of money being spent before we have evidence,” he said.
But he paused, at the end of the interview, to say how much he admired the staff of the HOME team. Young people entering mental health fields are desperate to find a meaningful way to address the catastrophe of homelessness. For them, he said, street teams “ignite the imagination.” He understood; he felt it himself.
“The people who are doing this, they do it out of love,” he said.
A drive to treat
As Dr. Koldobskaya drove between appointments, she scanned the roadside for patients. She has names for them, like Rabbit Lady, and Plastic Lady, La Brea Jesus and a man she is calling the Spoon Jabber, because he is always poking himself in the eye.
She was a medical resident, in her early 30s, when she first encountered a patient with psychosis. He called her a “reptilian” and, after shaking her hand, refused to let go of it. She felt that she had found a calling. “A lot of the reaction I get is, I want to protect them from the world,” she said.
She is a steely advocate of treatment, dismissive of the argument, sometimes put forward by public defenders, that refusing medication and living outdoors is a lifestyle choice. When the team petitions a mental health court to treat a patient involuntarily, it is often Dr. Koldobskaya who appears as an expert witness.
Once, when appearing before a judge who “was very much swayed by the lifestyle choice argument,” she gave a statement that consisted almost entirely of a description of the feces she had found smeared around the man’s campsite. Court officials later told her it was the most graphic testimony they had ever heard, she said.
“I don’t know why it has to be this intense debate,” she said. “I mean, people are rotting outside.”
With Michael, though, something stopped her from ordering a hospitalization. He was taking steps — tiny ones, but still, steps. His case worker, Mr. Gonzalez, was dead set against involuntary treatment, and every time the possibility arose, he doubled down on his trust-building visits. “I was like, we’re not placing Michael,” he said. “Not Michael.”
The team located Michael again three days later, curled on his side in front of a grocery store. In her bag, Dr. Koldobskaya carried a syringe of Prolixin, an antipsychotic. As she approached, Michael lurched to his feet and nearly fell down.
“Remember how we talked about a monthly medication?” she asked, hopefully.
He shook his head.
“No?” she said.
He shook his head.
“Can we maybe make a deal to do monthly meds?” Dr. Koldobskaya asked, but Michael had begun to shuffle away. She sighed. “He’s moving along,” she said. “Just slowly.”
Things were moving faster with Yoh, the man in the underpass.
He had warmed to Allen Ziegler, the psychiatric social worker who visited him . He offered up fragments of a remote past: At one time, Yoh said, he had studied psychology at Pikes Peak Community College, in Colorado Springs. He also shared, so quietly that you could barely hear him, the details of the epic mission that had led him to the underpass.
He had guided his followers onto a train, the Pineapple Express, and they were hurtling through space toward a place called Lior, a slab of floating concrete that measured 44 light years in length. He received orders, he thought from the C.I.A. The orders were sometimes arbitrary and cruel.
The voices, at times, forbade him to eat until he had defeated an enemy in battle, driving him at times to the edge of starvation. They also forbade him to leave the spot in the underpass. “That’s the only safe place in existence to be,” he said. “Of all the other coordinates and sectors.”
Mr. Ziegler did not push. When he finally persuaded Yoh to travel to a shelter where he could take a hot shower, they had gotten as a far as the door when Yoh began to panic. Mr. Ziegler saw this. He gently steered Yoh back to the car and returned him to his spot in the underpass.
This patient effort had brought them here: Yoh had agreed to take an injection of Abilify. On the appointed day, Mr. Ziegler parked his car, withdrew a pair of binoculars and trained them on Yoh, who was hunched in his regular spot. He watched as Yoh brought a flame up to a pipe.
He asked Yoh to come out to the parking lot, where Dr. Rab and a nurse were waiting. Yoh’s eyes flickered, as if he was tracking shadows in his peripheral vision. But after two weeks on an oral antipsychotic, he could carry out a conversation.
“Remember when I saw you on Monday, I told you that instead of taking a pill every day, we can take a monthly injection?” Dr. Rab asked.
Yoh nodded, obedient.
“Are you doing any kind of drugs?” the nurse asked him.
“Crystal meth,” came the reply.
“When was the last time you did it?” she asked.
“Today,” he said.
“You know, this medication will protect your brain from any of the damaging stuff that crystal can do,” Dr. Rab said. “So it’s a great thing you’re doing it.”
They were crossing a threshold. From this point forward, Yoh’s medication adherence was assured, and the outreach teams were released from the burden of delivering pills to him every day. But they were also bound together now, Dr. Rab said, because the team would need to monitor him closely for side effects.
“You can’t switch gears, because you have filled their body up to a certain level with medications, and you don’t want that cup to overflow,” he said.
While the nurse prepared the dose, Dr. Rab chatted with Yoh about anime, an interest the two shared, and promised to bring him a couple of graphic novels. “There’s a new one called ‘Solo Leveling,’” he said. “It is so badass.”
Dr. Rab had also brought Yoh a double cheeseburger, but that was for later.
“You want to just pull your arm out then?” the doctor asked. And Yoh did.
‘A gathering of my senses’
Michael, it turned out, would accept the injection on one condition — if his social worker, Mr. Gonzalez, was willing to sit beside him and hold his hand.
Certain things were changing about Michael. For the first time, he noticed that Mr. Gonzalez had a tattoo on his finger, and asked about it. Once, when the two men made a trip to the emergency room, Michael lay his hand on Mr. Gonzalez’s shoulder, looked him straight in the eye, and said, “Diego, thank you very much for your help.”
A week later, Michael agreed to check into a hotel and stood under a steaming shower, watching dirt run in rivers off his feet. Mr. Gonzalez was so thrilled that he ventured further — he placed a call to Michael’s mother, in Arizona. Maybe she had been looking for him all this time?
But it wasn’t like that. She knew where he was; every now and then, they would speak on the phone. “No one here can take care of him,” she told Mr. Gonzalez.
Then, in pain from a wound on his groin, Michael slipped out of the hotel and headed to the one place he felt safest: his old spot on Firestone Boulevard. Dr. Koldobskaya, now worried about infection, ordered a brief psychiatric hospitalization, but upon his release, Michael insisted on returning to the street.
“All that hard work I put in, and one minute, he could be like, I don’t want to be here,” Mr. Gonzalez said. “He just walks out. And then we go back to square one.”
As fall arrived, that is where Michael remained. Once again, there was a thick line of black dirt under his fingernails — but he no longer spoke about green men. His clothing was not torn or soaked with urine, as it had been before, Dr. Koldobskaya said, and that was a kind of progress. She had decided to let him stay where he was.
“Ultimately, this is an adult who legally makes his own decisions,” she said. “And so he is going to do what he feels is right.”
But in a tiny room in Hollywood, Yoh had begun a new life. He moved into a small hotel that has been taken over by the county for interim housing, where nurses delivered medication and meals were distributed three times a day.
He inhabited the room awkwardly, like someone who had lived outside a long time; at first, his meals stacked up uneaten in their plastic shells and began to fester. Mr. Ziegler reminded him to clean up, the way a parent might tell a child. Yoh still smoked methamphetamine — but, he told Mr. Ziegler, he did it less often.
On a single sheet of paper, Yoh wrote down a list of goals for the month of September.
Do laundry.
Invite over a guest.
Find a hobby.
He had agreed to provide his fingerprints, which Mr. Ziegler ran through a criminal justice database. The database recorded a brief stint in prison. Now Yoh had an age: 44. And a name. He was Eric Covington.
With no warning, during one of Mr. Ziegler’s visits, he blurted out these facts: He had been working in a call center in Colorado Springs when God spoke to him, telling him to quit his job. After that, he bought a bus ticket to Los Angeles, a place where he knew he could survive the winter outdoors. He thought this had happened 20 years ago.
One way or another, though, this mission had come to an end. God still spoke to him, but there were no more instructions from the C.I.A. — perhaps, he said, because “someone in a position of power noticed that it would probably be hard on a kid.” His head was clearer now.
“I felt a gathering of my senses,” he said. “Like, if you want to live, this is what you need to do.”
Perhaps the most striking change in Mr. Covington was that he showed a desire for human company. In the mornings, he left his small room and walked up and down Vine Street, closely observing the movements of pedestrians on the streets and considering ways to start up a conversation.
“The yearning to be able to connect with somebody,” he said. “It’s so intense.”
Mr. Ziegler tried to keep his expectations in check: Clients who move inside after years on the street often disappear without warning, gravitating back to their spots. But for now, it was one body fewer outside. As he left the apartment building one afternoon, Mr. Ziegler watched Mr. Covington in the courtyard for a moment and saw something that made him think things would be all right.
A man walked up to Mr. Covington and asked him for a cigarette.
Mr. Covington handed him one.
Then the two men, smoking, began to converse.
The post Under a L.A. Freeway, a Psychiatric Rescue Mission appeared first on New York Times.
