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Sam, as we will call him, was proudly wearing a luminescent football jersey and a big smile on his face. He had spent 25 years living on the streets and prisons of California when I met him in Long Beach as I toured "The Village." He had achieved four years of being successfully housed, out of prison and away from the brutality of the streets. At first, he told me, he would just show up at "The Village" asking nothing but taking a shower or a sandwich. When I asked him what got him engaged in the program and making a life after all the years on its margins he said, "they did what they said, for over a year, then I trusted them."
The Village, a comprehensive mental health center in Long Beach, California, under the aegis of The Mental Health America of Los Angeles (MHA-LA). It was started as a urban demonstration project 20 years ago as the state experimented with the question of what are the best services to provide those whose pained lives were beyond their communities' know-how about how to help. The program strained, even back then, the public treasuries that paid for their daunting medical, social service and correctional expenses. In a remarkably innovative financing design The Village was paid a flat annual fee per person to deliver what set of services it considered would make a real difference. Outcomes would be measured in terms of impact on quality of life, including gainful employment and being part of a community, as well as reductions in hospital, jail or prison stays.
Mark Ragins, MD, was one of a group of dedicated staff there to launch this experiment in quality care. He remains the medical director today. Initially they served anyone who was disabled by mental illness, but over time they took the Malcolm Gladwell approach (see Million Dollar Murray, The New Yorker, 13 February 2006) that focuses on the high users of services. That means seeking out and providing for the chronic homeless and those with histories of long term institutional care, including foster care, hospitals, jails and prisons. About 400 people are served today.
Ragins, referred to as Dr. Mark by consumers and colleagues alike, now spends his time on the Welcoming Team, where the most frightened and emotionally scarred of recipients begin. "I thought I could have the most impact on people in the first three to six months and help them move on. I focus on engagement, compassionate listening, relationship building, building hope and creating an expectation of participation in their own recovery." He is a bit of a guru in the world of public mental health and serious mental illness, traveling and teaching others the art of what I like to think about as meeting people where they are and taking them where they are afraid to go. When Steve Lopez of the LA Times was looking to help Nathaniel Ayers, the anchor for his Pulitzer Prize journalism and the character portrayed by Jamie Foxx in the critically received film, The Soloist (2009), and to study, as well, the street homeless of southern California, he contacted Ragins who guided him through his work.
No one enters a wrong door at The Village since there is no wrong door: everybody is welcome and asked what do you want? Answers range from a shower, day labor, medications, and getting on Medicaid. "You ask, we try" is their ethos. The Village takes in "refugees" -- people who feel estranged from their community which has yet to find a way to house or feed or deliver anything but emergency medical services to these souls. At The Village they believe in charity and not making demands that their consumers are not yet ready to meet, including taking medications or getting off drugs and alcohol. Low demand, progressive expectation is the model where you begin low and slow then expect more as a person trusts you are acting in their interests to help them get what they want and need.
But the world has changed since 1990 when The Village began. They now depend on Medicaid and HUD (the Federal agency for Housing and Urban Development) funds for their overall program, including a drop-in center and housing designed for people with serious mental illness and addictions. But their efforts are often thwarted by lack of affordable and supportive housing (where services are located or linked with the tenants), absence of jail diversion programs, and California's budget woes that have eroded mental health services despite Proposition 63, the millionaire's tax to augment county paid mental health services. In California, as well, getting on Medical (Medicaid) has become an ever greater challenge. And even when someone has Medical it pays for traditional medical services but not for rehabilitation and housing, both essential to ending the merciless cycle of institutional and street life and becoming a contributing member of a community.
When you ask someone with a serious mental illness what they want they respond with the very things we all want: a home, a job, a car and a date on the weekend. The mental health field is slowly adopting a recovery model of care. Instead of seeing people with chronic illness as fated to a life without prospects recovery holds that people can rebuild their lives. That takes support by professionals, family and community. That means providing treatment as a person will take it, step by step, with increasing expectations for a life of safety, health and community. It means offering hope, respect and trust. Recovery can work, but sometimes it takes The Village.
The opinions expressed herein are solely my own as a psychiatrist and public health advocate.
Lloyd I Sederer, MD
Visit Dr. Sederer's website at www.askdrlloyd.com - for questions you want answered, reviews and stories.
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