Off the Streets and Into The Courtroom: Psychiatric Street Medicine, Forced Psychiatric Care, and the Assisted Community Treatment (ACT)

It’s no secret that psychiatry is a field riddled with controversy. What is more personal, more sacred, more defended, than the autonomy to decide what’s best for our health - even more so, our own minds? Most of our medical laws have been crafted around the preservation of just that: the inherently venerated human right to choose. 

But like most issues around human rights, it becomes more complicated when you consider the reality of living in the society we do. How do we approach situations like those surrounding severe mental illness (SMI) and the homeless population, where debilitating psychiatric conditions and/or years of substance abuse have impaired a person’s ability to make choices for their own wellbeing, where a rejection of care comes at their own detriment? 
 

Urban Psychiatry: A New Type of Needle Pushin’ 

Here in Hawai’i, especially within the city streets of Honolulu, there is an increasingly common scene: houseless folk pushing carts through city streets, sheltering in jerry-rigged structures on beaches, and camping behind bus stops. The public reaction to the increase in homelessness has been less than empathetic, to say the least. Anti-homeless architecture is becoming a disturbingly widespread phenomenon, as businesses and the government attempt to cover up the problem without actually addressing the underlying issue. Bus-stop benches are divided into seats to dissuade lying down, public parks display signage prohibiting “camping, tents, open fires, and overnight structures”, even sheltered overhangs outside of shop windows are now built with lines of blunted spikes. Despite this, as of 2022, Hawai’i sported the 4th highest rate of homelessness per resident, nearly double that of the national rate. Even more disturbing–28% of the homeless population identified as Native Hawaiian. As it turns out, the issue of suffering and homelessness remains, even if you try to whisk the evidence out of sight. 

Hawai’i has grappled with this problem for years as rates of homelessness continue to rise incrementally each year. Add in the unique problem of living on an island with limited land, resources, and a history of poor governmental budgeting, and suddenly the problem feels much larger in scale. But this is not an impossible issue, nor is it entirely in the hands of bureaucracy. In recent years, a team of psychiatrists have employed a boots-on-the-ground approach to assisting those with chronic mental illness experiencing homelessness. 

Enter: The Institute for Human Services (IHS), a non-profit organization dedicated to preventing and addressing homelessness in Hawai’i. While IHS has been operating in some capacity or another since its humble origins as the Peanut Butter Ministry in 1978, some of its more recent work in the past two decades has been through the implementation of “psychiatric streetside services”. A small team of health care providers–usually composed of doctors, psychiatric practitioners, and social services workers–meet regularly with houseless individuals in an attempt to forge a relationship that might get them into housing or coax them into voluntarily taking medication for chronic mental illness. These individuals are generally suffering from a debilitating psychiatric condition, such as schizophrenia, in which symptoms such as paranoia, psychosis, and detachment from reality prevent them from being able to care or seek help for themselves. Some individuals have been living on the streets for multiple decades, accompanied by a history of incarceration and substance abuse. 

The IHS team meets with houseless folks on a monthly basis to discuss care, treat wounds, and build a relationship with these people who are otherwise overlooked by the State. And for a few, this person-to-person rapport is enough. After meeting with the IHS team regularly, some houseless individuals suffering from mental illness elect to take medications to treat their SMI, usually in the form of long-lasting injectable antipsychotics, such as paliperidone or aripiprazole lauroxil. These drugs are applied to treat the symptoms of schizophrenia and are administered every four to eight weeks via intramuscular injection. The development of long-lasting, injectable antipsychotics has been a boon to the treatment of SMI within the homeless population. This is due to the Catch-22 of mental illness: because symptoms of SMI impair your perception of reality, some people do not believe they are sick or in need of help and thus won’t take a daily medication, such as a pill. 

In the Eyes of the Law

Despite all of this, there remains cases in which a person is too disabled by their psychiatric condition to self-advocate or are considered a danger to themselves and others. These people tend to have a history of chronic homelessness and incarceration, and substance abuse can be a common byproduct as well.** 

**To quickly clarify a common public misconception: yes, substance abuse is generally the byproduct of mental illness, not the cause of it. It’s most often a form of self-medicating or easing the hardship of a difficult situation, but drug use can quickly spiral out of control and addictions become a significant part of the barrier to treatment and/or housing. In the words of B Lovee: I’m tryna heal my streets, but the drugs run it. 

 In the event that an individual is treatment-resistant, violent, suicidal, and a willing relative or guardian cannot be found to oversee their care, the Assisted Community Treatment Act (ACT) becomes a consideration. An interested party (such as a family member) or medical provider files a petition to a judge so the individual is required to undergo outpatient treatment, usually in the form of medication, such as the aforementioned long-lasting injectables. After the ACT petition is filed with the Court, an attorney (referred to as the Guardian ad Litem, or GAL) is appointed for the patient. The GAL is assigned to the advocate for the patient and makes decisions surrounding their case management, medications, and treatment, as the individual must be shown to lack the capability to make these decisions themselves. However, the patient is allowed to remain within the community, with the hope that the medication will make them more receptive to other medical and social assistive services. 

The function, implementation, and history of the ACT will be further discussed in the second part of this ongoing blog series. Stay posted for part two discussing this controversial psychiatric law. 

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Empower your family member with the care they deserve. Schedule a consultation with Dave Fields today by calling (808) 207-9800 for Mililani and Honolulu, or (808) 242-1660 for Wailuku. Let us be your partner in navigating the journey towards mental well-being and recovery.