Nathaniel’s case, and ours

READERS OF THE TIMES HAVE watched Nathaniel Ayers -- musician, schizophrenic, street dweller -- creep for eight months toward a better life under the empathetic eye of columnist Steve Lopez. Ayers’ is a hard case, mired in decades of sporadically treated mental illness, cemented by habit to a patch of sidewalk at the mouth of a tunnel in downtown Los Angeles. He also is the public’s window into the promise and difficulties of a new approach in California to cases like his, offering assistance for the whole person rather than treatment for a disease. For the first time in years, thanks to a 2004 ballot initiative, public health agencies will have enough funds to seek out people like Ayers rather than limit who can be helped.

What Lopez pulled together on Ayers’ behalf -- a cadre of patient caseworkers, a freshly painted apartment with supportive services, a reconnection with professional classical musicians, encouragement to resume treatment for his mental illness -- has not pulled Ayers off the street. He still sleeps on the sidewalk, believing that the spirit of Beethoven will protect him. But Ayers’ view of himself is changing; his connection to a community may be taking hold.

Before this violinist of the streets caught a curious newspaperman’s eye, Ayers seemed beyond help, to himself and the public health system. He couldn’t keep appointments, and he spurned medication or other treatment. Many such people end up in jail, the state’s biggest single repository for the mentally ill.

A new year, a new start

Now, with a dedicated tax bringing in more than $700 million a year statewide for mental health services, thousands more people have a chance at better-tailored assistance.

The help will not wipe away the complex hell of Los Angeles’ skid row, but expanded programs to help people off the streets would separate predators from their most helpless prey, giving law enforcement a moral clarity it now lacks.

Voters in November 2004 passed Proposition 63, the Mental Health Services Act, adding an extra 1% to the income tax of those making $1 million or more per year. Such dedicated taxes are a poor way to legislate, yet backers saw no likelihood of getting the hundreds of millions of dollars needed to properly treat the state’s indigent mentally ill from the state Legislature.

Now that the money is flowing, mental health advocates who wrote and backed the Mental Health Services Act must implement a tidal change in the culture of public mental health.

The money is being divided between state and county programs, targeting such groups as disturbed young children, hardened street dwellers and the isolated elderly. A state oversight board led by Darryl Steinberg, the former state legislator who was the driving force behind Proposition 63, is assessing county plans. Eventually, most of the money is to be spent through counties; the work is daunting, and success won’t be immediate.

One of the models for the new culture is the Village in Long Beach. It is run by the Mental Health Assn. of Los Angeles, a nonprofit whose leaders were instrumental in writing Proposition 63. The Village’s teams of social workers, psychiatrists and counselors offer menus of housing, employment and treatment options to severely mentally ill adults and to disturbed young people who have had their first brushes with the law. Its “members� suffer from schizophrenia, bipolar disorder or depression, sometimes in combination with addiction.

It’s a costly approach when compared with sporadic visits to a county mental health clinic. A Village client’s tab averages about $18,000 a year. But more of them end up recovering, housed and employed or on Social Security disability income, which defrays housing and treatment costs. Because the ill help define their own treatment, they are better able to stick to it, say proponents.

Such programs seem a little less costly when compared with the thousands of dollars in emergency-room treatment racked up by the indigent when their untreated illnesses reach a crisis state. Or the cost of jailing the mentally ill for offenses both petty and grave. There’s also the human cost of ignoring the mentally ill, as so often happens now. It can be seen in the bodies regularly found on skid row at dawn -- four of them on one recent day, lost people killed by disease or an overdose.

Another admirable model is the meticulous conversion of an old downtown L.A. hotel, the St. George, by the Skid Row Housing Trust. It offers big-windowed rooms, along with on-site counseling, psychiatric services, addiction programs and a staff nurse. It boasts a large communal kitchen, laundry facility and a comfortable lounge equipped with computers. The St. George staff seeks out and serves the hardest cases -- the mentally ill, the HIV-positive and addicted who are chronically homeless.

Now, due to the explicit requirements of Proposition 63, this comprehensive approach is becoming the law. Families of the mentally ill are part of the planning, along with businesses and law enforcement.

Ultimately, success will depend on whether large bureaucratic cultures, including the L.A. County Department of Mental Health, can transform themselves, shedding outdated rules and states of mind. It will depend on thorough state oversight and assessment of programs vying for funds. It will depend on public education that encourages the mentally ill and their families, in culturally effective ways, to seek help quickly rather than tough it out. It will depend on the cooperation of other government bodies.

The attention being paid to skid row and homelessness by Mayor Antonio Villaraigosa and the City Council is encouraging; last month, Villaraigosa announced federal funding that will bring the city’s housing trust fund to $100 million for this year. Yet the city, with its housing funds, and the county, which will control treatment funds, soon must develop better ways to work together to combine shelter and supportive services.

Beyond one man’s story

Thanks to Steve Lopez, we all now know the story of one classically trained musician lost to schizophrenia who is slowly, erratically trying to pull back from the brink. We can grasp how hard Ayers’ struggle will remain. But what if he had been helped more persistently before years on the streets hardened his illness and his suspicions? Recent research hints that he might have been more able to cope with ordinary life, if not cured.

Pulling together lives before they descend to the streets or to prison is the ultimate goal of Proposition 63. We hope the people and agencies handed this task in the new year are up to it.