Editor’s note: This article is the second in an SMDP series examining efforts to address homelessness in Santa Monica.
Like most doctors, Dr. Brian Benjamin has a list of patients to see everyday. Unlike most doctors, he has to go out and find them – and he’s not always able to.
Benjamin is a psychiatrist who works with the People Concern, a non-profit that provides homeless services across the Los Angeles area. Several days a week he joins the organization’s Westside outreach team to provide psychiatric care to individuals living on the street in Santa Monica.
On a recent Wednesday, the team started the morning gathered around a table in the conference room at their Santa Monica office. They discussed who needed to be seen that day, where they were last spotted, what they needed and the urgency of their case.
After the meeting, Benjamin packed his bag with medical equipment and medications for the patients he was hoping to see that day, including several doses of antipsychotic drugs used to treat schizophrenia, bipolar disorder and other mental illnesses.
Studies have shown that a significant portion of the homeless population in Los Angeles suffers from some form of mental illness. Even if individuals are not experiencing severe mental illness when they fall into homelessness, living on the streets comes with significant trauma that can worsen existing issues and lead to new ones.
Further exacerbating the crisis is the fact that this population is one of the hardest to treat.
"With people being outside, it’s so hard to get consistent follow up, it’s so hard for people to take their medications, they get stolen or lost," Benjamin said.
One tool psychiatrists like Benjamin use to get around this issue to some extent is a type of injectable medications.
"There are a couple of these antipsychotics that they’ve created in injections, where you give someone an injection and it lasts at an even level in their body for an entire month," he said. "So it’s the equivalent of taking a pill every single day but you don’t have to take it and you get the same effect."
Administering the medicine on the street
On this particular day, Benjamin was hoping to find Sarah, a woman he met for the first time a month ago when he gave her the first dose of Abilify, an injectable antipsychotic, after she was identified by the outreach team as someone who would benefit from medication.
"When I first met Sarah last month it was pretty apparent that she was having a lot of psychotic symptoms," he said. "One of the symptoms of psychosis is being really disorganized in the way you think, so it’s kind of hard to follow her a little bit… She also is plagued with really bad hallucinations. She shared with me that an abusive ex partner, she hears that person's voice in her head saying he’s following her, that bad things are going to happen to her, things like that."
Benjamin said that the relationships outreach workers build with people experiencing homelessness is key to providing care for people like Sarah.
"I think the fact that there are these teams in place that get to know people… I think it gives me access to people that otherwise would never come into clinics or never really be open to meeting a psychiatrist," he said.
"Long term engagement and creating relationships is like the only way because a lot of people out here don’t trust the system," said Zachary Coil, director of the westside outreach team. "They don’t want to get involved or engaged and so you could walk up to somebody and say ‘hey we have this resource’ and they would not be interested in it because they’ve had bad experiences."
Benjamin did not find Sarah at Reed Park, the first place he looked, but an outreach worker called to tell him they saw her at a nearby 7-Eleven, sitting next to a shopping cart piled high with her belongings.
Sarah recognized Benjamin right away and got excited when he told her that he could give her another Abilify injection. He asked her if she had noticed any differences after the first one and she said that she had felt less paranoid, anxious and fearful and that she had stopped hearing and seeing things.
After administering the second shot, a process which took only a few minutes, he asked if she was still using any drugs. She responded that she still used meth but that she wanted to stop, which Benjamin said the medication may also help with.
"My hope is that as the medication is working more and more, you won't even need the meth anymore, you’re going to feel a lot better, that’s my hope for you," he told her.
As he walked back to the outreach team’s van to head out in search of the next patient, he said that Sarah genuinely seemed to be doing better.
"I'm just noticing when I'm talking to her, even though she's not totally organized, she's more organized than she was before," he said. "And she subjectively is saying like, ‘I noticed my mood was better, I noticed I was feeling less overwhelmed…’ so it was really good to hear that she had a pretty good response to the medication."
With patients living on the street, like Sarah, Benjamin said it can be hard to tell if their symptoms are caused by an underlying condition or if they are primarily drug-induced. The way a patient responds to a medication can be a helpful indicator.
"The fact that it worked fairly well for her and that she found it really helpful tells me that it might more likely be an organic, primary psychotic illness like schizophrenia," he said.
Knowing this allows him to figure out the best way to treat patients and make it possible for them to reach a place where they can have productive conversations about their situation and possible options.
Limitations of street psychiatry
Later that day, walking down Broadway near the Third Street Promenade, Benjamin saw another patient, Jeremy, sitting at a bus stop. Jeremy was not on the list for that day, but Benjamin said he was due for his monthly dose of antipsychotic and that it would be best to give it to him now because he did not know when they may see him again.
Jeremy agreed to receive the shot and Benjamin chatted with him about how things were going as he administered it.
Afterwards, Benjamin explained that, unlike with Sarah, the injectable medication did not have as noticeable an effect for Jeremy. He continued to give it because he said it was still better than not doing so.
"Unfortunately there's a kind of aspect of schizophrenia, a type of symptoms that don't get treated by the medications very well, they're called negative symptoms," he said. "So it's like people being really withdrawn or flat or unmotivated, or uncapable, of motivating to take care of their basic hygiene or whatever – and the meds don't really address those symptoms."
He said there are medications that exist which are better suited to these types of symptoms that Jeremy would likely benefit from, however they are only available in pill form. This makes them an unrealistic option for him as long as he is still living on the street.
"If he was in an environment where I thought he could take oral meds consistently, like if he was at like a boarding care or a nursing facility or somewhere where he had support of a med room and people that could remind him to take his meds every day, I would try different meds because I think it's possible that a different medication would help more, or a combination of meds would help him more," he said.
He said Jeremy had expressed interest in going into a shelter in Santa Monica and he was hopeful a spot would soon be available for him in one of the People Concern’s facilities.
Through the People Concern, Benjamin continues to work with his patients when they move off of the street and into shelters and even after transitioning to housing.
"The transition to housing is really challenging for so many reasons, it's not like this magic cure-all where everything is better," he said. "Certainly it's a big deal to be housed, but also all the things you're carrying with you, your mental health issues, your addiction issues, all these things, you carry them with you into your housing."
"So I think the fact that we keep services through that, for often years, is really helpful and it helps people in that transition and it helps them at a time when they can actually build upon things," he said.
One such patient going through this transition is Elaine, the last on Benjamin’s list for the day, who recently moved into the People Concern’s Cloverfield shelter.
Signs of success
Elaine arrived at Cloverfield in December 2022 after living in homelessness, being assaulted in a park and ending up with a broken leg. She said she had spent days in pain, in a broken car, unable to move when People Concern outreach workers found her.
Now, several months later, her leg is healing and she meets with Benjamin regularly to discuss her mental health. He recently started her on a new medication to treat depression which, she reported at the recent visit, seems to be helping.
"When I first met her, people were like ‘she'll never take any medication, she's really suffering,’" he said. "But she kind of just seemed to open up to this one last medication I think might really help her and so I'm really excited."
"If she was to take this medication, and it was to really help her and she was to get housed and her mood was doing a lot better and she was stable, and she was finding a life worth living and a quality of life for her, I think that's certainly a success," he said.
However, similar to Donovan Wilkes from Downtown Santa Monica’s outreach team who was featured in the previous article of this series, he said success in this field needs to be measured in other ways as well.
"So I think there are these tangible successes that are certainly ultimately what we measure things on and those are really important, but I think kind of beneath that there's like a success in just spending time with people and caring for them."
While he sees value in this individual type of work, he said he knows there are large scale systemic issues that need to be addressed to create meaningful change.
In upcoming articles we will explore some of these issues through taking a closer look at the City’s shelter system and housing process.
