Harmony lay in a 6-foot-wide stream of her own waste, swaddled in a blanket infused with feces. She propped up her matted head on her right arm, looking up at two downtown ambassadors from the community improvement district who had come out to ask her to move for the fourth time in a week. They needed to pressure wash the sidewalk.
Harmony is not her real name. Atlanta’s powers that be know who she is.
Phillip Spillane, a good friend of mine among the ambassadors, had called 911 to get paramedics to take her to Grady Hospital that Friday. He has made this call about once every two weeks, when the state of Harmony’s squalor becomes too much to bear for an observer with a soul.
I came upon them as paramedics were piling back into a Grady ambulance. I watched them drive away, an impassive expression on the face of the paramedic in the passenger seat as she watched Harmony, who remained on the sidewalk.
It was the same expression on the faces of most of the people walking by. I’ve seen it every time I’ve come downtown to Atlanta to talk with her. It’s not that passersby don’t notice her, but people make an immediate mental calculation about their ability to help someone in this kind of distress. The social reaction — the human reaction — left over is a carefully deliberate nonchalance meant to provide some dignity to a person in a state of public humiliation and to retain some dignity of their own on the scene of a moral catastrophe.
Of course, some people realize that they’re about to step in her shit and can’t keep from scowling.
This story starts with Harmony. It does not end with her.
Harmony wants to be seen. Her survival depends on being seen. Dangerous things happen to people out of sight, in her mind. She won’t go into Woodruff Park next to the Walgreens for fear of being attacked. But on the sidewalk, people will see her, and some will bring her food as an offering to their own conscience. The lights on Peachtree Street will keep her safe in the darkness, if one can call any of this safe.
Harmony called out to me by name. It shocked me.
In what universe would someone fighting to keep the black flies from airlifting her off the sidewalk, with all the cops and social workers and the musical dance number of homeless people around her, have the presence of mind to remember my name?
In that flash of casual lucidity, I saw all of her problems illuminated.
If Harmony had the wit to remember me, then, perversely, it meant that she might not be unwell enough to be committed involuntarily to a hospital for treatment. Hearing my own name pissed me off.
Harmony isn’t exactly unique; thousands of people in Georgia have mental illnesses and developmental disabilities and addictions, flitting into and out of the state’s care in between long bouts of homelessness. But Harmony is at the center of the Familiar Faces project, an official list of people with severe and persistent illnesses whom Fulton County, where Atlanta is located, and the state desperately want to get off the street and out of the county jail.
I would argue that no one currently experiencing homelessness in Fulton County, if not the state, requires more help than Harmony.
I would argue that no one currently experiencing homelessness in Fulton County, if not the state, requires more help than Harmony.
And yet despite millions in resources, much of which the state cannot figure out how to spend, Harmony remained unhoused at the foot of the iconic Coca-Cola sign above the Walgreens at Five Points — in the heart of Atlanta — as she has on and off for years, in a state of abject human degradation, with all of this misery taking place less than 100 yards from the very steps of Georgia’s Department of Behavioral Health and Developmental Disabilities headquarters.
The people who can help her can see her from their offices. They might walk by her on the way to lunch.
We spend less to treat mental illness than we should. As a result, Georgia is dead last in the 2021 national rankings for access to mental health care, as measured by the nonprofit advocacy group Mental Health America. Our miserable placement comes because poor and working-class people cannot afford routine mental health care — Georgia did not expand Medicaid, after all — and because we have about half the mental health providers as the national average.
Harmony has been the subject of intense discussions with the overseers of a federal consent order with Georgia that requires the state to prevent people with severe and persistent mental illnesses from falling into homelessness after being discharged from state facilities.
But a tug of war between the state, city, county, and others has made it difficult to figure out who should foot the bill for her care. Simple housing seems inadequate — she probably needs residential nursing assistance, since she can’t clean herself, and no one appears to be willing to provide housing without that care. The hospitals don’t want her because she doesn’t want to be there. Jail simply exacerbates her mental illness, with no easy alternative for police or social workers to use. And so she is left like an incontinent animal in the backyard, treated primarily as a sanitation problem.
I didn’t want to focus this story on Harmony. I don’t want to exploit the image of her crisis as some act of poverty porn without being able to help her. I have been wrestling with the question of consent, because it is hard to imagine someone living like this who is well enough to participate in the telling of their own story. I say this, though she has said she wants me to write. Frankly, I didn’t believe her until the day she called me over by name. It meant that her memory was relatively intact.
And that’s the problem. Because if she’s lucid enough to consent to my reporting, then she’s lucid enough to refuse treatment, which she does regularly. Harmony’s plight highlights the failures of Georgia’s health care systems — and that makes the story worth telling. The questions I hope to raise are whether we should accept that Harmony’s stated demand to be left alone should be enough, why it takes so long to act, and what our moral and legal choices look like.
Harmony is 38 and has been in and out of state hospitals for much of her life, she told me. She doesn’t like to stay there. She will, in fact, fight her way out.
Held at a Piedmont Healthcare facility in January, Harmony got mad when a guard asked her to stay in her room, according to court records. She pushed him, then started smashing computer equipment. Police charged her with a felony — the first after a long line of misdemeanors — for breaking a laptop. She spent 123 days in jail in Newton County before being convicted and sentenced to time served in May, with five years of probation and a required mental health evaluation.
She told the Newton County court that she was paranoid and schizophrenic, had a ninth-grade education, and was at the time prescribed a suite of psychiatric medications: Seroquel, Depakote, Geodon, Haldol, and Risperdal. She also said she was using drugs.
Judge Layla Zon accepted her guilty plea after a few questions to see if Harmony understood what she was agreeing to.
“I am also going to find on the record that the defendant appears to be competent based upon the time that I spent asking her questions,” Zon said. “She also appears to be coherent, very responsive appropriately to my questions. She is being medicated for the medical diagnosis that she has of paranoid schizophrenia. And that medication actually helps her understand the proceedings rather than impair her ability to understand the proceedings.”
After the plea, Harmony spoke up, according to the court transcript.
THE DEFENDANT: Can I ask you something?
THE COURT: Yes.
THE DEFENDANT: Can I ask you something? I know that you the judge and lawyer — judge, lawyer, help, case dismissed.
THE COURT: What was your question?
THE DEFENDANT: Judge, lawyer, help, case dismissed.
THE COURT: Judge, lawyer does what now?
THE DEFENDANT: I said judge, lawyer, help, case dismissed.
THE COURT: What about the case being dismissed? I don’t understand your question.
THE DEFENDANT: I said help, case dismissed.
THE COURT: You want the case to be dismissed?
THE DEFENDANT: I said, I’m telling you all four names, four names y’all said. I’m telling you four names: Judge, lawyer, help, case dismissed.
THE COURT: Okay.
THE DEFENDANT: I said that’s what I wanted to tell you.
THE COURT: You wanted to tell me to dismiss the case?
THE DEFENDANT: Huh-uh. I had wanted to tell you that.
DEPUTY: I’m sorry. Is she in court right now?
THE COURT: Yes.
THE DEFENDANT: Yeah, I’m in court.
THE COURT: But I can’t understand what she’s saying. Judge, lawyer, help —
THE DEFENDANT: I said I had wanted to tell you something. That’s all I wanted to tell you.
DEPUTY: She just wanted to tell you those words.
THE DEFENDANT: I had wanted to tell you something.
THE COURT: Okay. You wanted to tell me judge, lawyer, case dismissed?
THE DEFENDANT: Yes.
THE COURT: Okay. But you told me earlier that you wanted to plead guilty to the charges.
THE DEFENDANT: Yeah. I said — I just said that — really I took my time served. But I just said case dismissed. Other than saying time served, I said case dismissed.
THE COURT: Okay. Well, I can’t dismiss the charges because the State is going forward. The prosecution is moving forward with this case. And that’s why you have an option of pleading guilty or going to a jury trial. And you told me that you wished to plead guilty.
DEPUTY BELL: I think she was trying to tell you she knows those words.
THE DEFENDANT: I said, can I — can I ask you this? Can y’all give me time served?
DEPUTY BELL: She’s trying to tell you she knows those words.
THE COURT: I did give you time served. I sentenced you to five years on —
THE DEFENDANT: I thought Eddy Cossio —
THE COURT: I sentenced you to five years on probation and the jail time that I ordered that you have to serve I’m giving you credit for time served. Now, where do you —
THE DEFENDANT: Okay. Okay.
Harmony told the court she was homeless. The court instructed probation to send her to the Rainbow Community Shelter in Covington because her uncle would no longer take her in. (I have been unable to locate her uncle.) Three days later, the shelter kicked her out for misbehavior, and she found her way back to a downtown Atlanta street corner.
People with serious mental health problems in Georgia’s hinterlands almost always find their way to the streets of Atlanta. The most common service delivery strategy in “conservative” counties for homeless people or people who need drug treatment or women running from an abusive spouse is a bus ticket to Peachtree Street. It keeps taxes low and lets them brag about how much “cleaner” their communities are.
I spoke with Harmony’s probation officer in Newton County. Harmony never received the post-conviction psychiatric evaluation required by the court. She has never made a probation meeting. At first the officer was only marginally aware that Harmony was even on her caseload. Harmony did have an active warrant for her arrest for violating her probation, not that anyone — anyone — really wants her in jail. Because what’s the point? Unless it’s to force her or someone else to clean her, in ways that are likely to be traumatizing to all involved.
I dream of shit.
I stepped in Harmony’s waste as I walked over to her. I didn’t realize it at first, of course. I felt the squish on my shoe as I approached. Her shit was everywhere. I scraped my sole on the sidewalk without thinking, then realized what had happened. I tried to ignore it.
Harmony was nude from the waist down, covered with a blanket, as usual. Her thin top exposed a chest full of open sores. Some had healed and scarred over a bit since the last time we spoke. Her 300-pound frame was dusted in a light coating of her own feces. A cloud of black flies buzzed around her.
Harmony asked me for food, but I didn’t have time to run to Rosa’s Pizza for her preferred meal of a pepperoni slice. She then asked for pen and paper. I walked into Walgreens to buy some. The smell stayed with me. I couldn’t tell if I was imagining it or not. I wondered if I was radiating the smell of her waste as I picked up a notepad and some Sharpies.
I handed them to her, along with a bag of gummy bears, and she began to fill four pages with one-word lines:
I asked Harmony what they meant. She sort of shrugged and quietly said that this was her. She was describing herself. Perhaps. She was very quiet.
Harmony wanted fresh blankets. I said I wasn’t in a position to get some for her right then. She offered me some of her gummy bears. I politely refused. Harmony saw a white cardboard paper lollipop stick on the sidewalk. Wrapped in the soiled blankets, she wasn’t able to reach it. She asked me to give it to her, so I picked it up off the shit-smeared sidewalk and handed it over. She started cleaning out her right ear with it. And I left.
I went to lunch. I sat away from others, wondering if my shoe still smelled of her. I couldn’t go home. The entire interaction, punctuated by my own impotence at being able to resolve anything for her, left me vibrating with a kind of moral fury I didn’t want to dump in my own house. I went to a movie instead — the theaters remain mostly empty on Friday afternoons. I took a paper towel to my shoe in a sink, found a private spot in a dark corner, and wept where no one could see me.
I had spoken with that crew four days earlier as they were bundling a man I knew well into the back of an ambulance for the third time in a month. I stopped to chat. He’s one of a cast of characters better known downtown by nicknames like Ooo-wee or the Angry Man or Smiley. I know their real names. My friend has a history of passing out drunk on the sidewalk, as he has done for the better part of a decade. He perked up a bit when he saw me. We’ve been speaking for years about his need to stop drinking and get off the street. He was sober for a while a couple of years ago. I wish it had lasted longer.
I asked the EMTs what they would want the public to know.
A paramedic took out his phone and pulled up a calculator. “Every time an ambulance comes to take him to Grady, it costs $1,700,” he said. “That’s before he walks through the door.” They pick him up once a week. The state of homelessness and inebriation my friend lives in costs the public about $88,400 a year at minimum, he said. For that much money, four or five people could be provided permanently supportive housing.
They knew Harmony well. When I brought her up, they just shook their heads. They come to take her just as often — only she won’t go.
I asked Harmony that day if she was still OK with me writing a story about her, and she said yes. If someone offered her an apartment, I asked, would she take it? She said yes to that too. I asked her if she would go to a nursing home. She said no.
I dreamed that night about what a jail would do with Harmony. How would they clean her? Would they just hose her down like in a prison movie, or would they give her the dignity of cleaning herself? Could she take a shower? How would they clean the shower? I awoke with a start after dreaming about being trapped in a stopped-up public toilet stall with no toilet paper and people peering through the gaps in the door.
The next morning, paramedics arrived to take Harmony to Grady and then to a state hospital, come hell or high water. Harmony had finally drawn enough attention. She refused to go willingly, as usual. This time, they shot her full of the aggression-reducing antipsychotic Haldol and carted her away anyway.
But this story isn’t about Harmony.
It’s about all the things that have to be broken to leave someone in Harmony’s state, living in her own shit on an iconic Atlanta street corner for five months.
It’s about how we react to seeing someone like Harmony — the same someone, over and over — or to squalid tent encampments under a highway, or to someone clearly out of their wits begging people in cars at a stoplight. We ask ourselves what in the cherry-flavored fuck are we doing with our tax money, if this is what we get. How can we call this a “developed” country when this kind of dismal wretched misery greets us in public places? Who do we hold responsible for this failure?
And I’m not talking about reactionary libertarian sociopathy. I’m not entertaining amoral bastards who shout “Get a job!” from their SUV window and then call the cops to get rid of “undesirables” in their neighborhood, patting themselves on the back for how their hard work made them successful.
Hundreds of thousands of Americans have schizophrenia. Schizophrenia cackles at Darwinist meritocracy.
I want people to understand why it takes so damned long for what we laughingly call “the system” to help someone like Harmony.
People experiencing chronic homelessness driven by mental illness have often been burned by the system. For someone wrestling with delusions, it can take dozens of contacts simply to convince them that a caseworker isn’t a figment of their imagination.
Even when a caseworker gets a client to say yes, they are met with a system that is underfunded, poorly coordinated, riven by competing interests, the last political priority of policymakers, and dependent on private housing providers that manifestly do not give a shit about keeping people off the street.
“Mental health is messy,” said Fulton County Commissioner Bob Ellis, in a hearing about establishing a diversion center — something homelessness strategists have been calling for for years. “It involves so many different layers, people want to get into whose role is it. That’s part of the reason stuff never gets done. It’s the state’s role, the county’s role, the city’s role, law enforcement’s role. It’s the family’s role because they need to take care of it. We can get caught in that trap as well.”
Harmony is unique. And yet there are at least 100 Harmonys on the streets of Atlanta.
The county knows each of them by name. There’s a list.
A few years ago, folks working on strategy around mental illness and jail wanted to better understand who the “highest utilizers” were. Who are the people who bounce in and out of jail most frequently? Who is taking a $1,700 ride to Grady once a week? From these questions arose a data project to identify and target them for intensive outreach and prioritized service.
Fulton County now calls this the Familiar Faces program. We used to call them frequent flyers. (I have to wonder if Delta Air Lines objected.) The top hundred make the list.
Kristin Schillig, who works for the Fulton County courts, is the keeper of that list. Schillig and I have been friends for years. We worked together on a judicial task force trying to get people with mental illnesses out of the county’s jail. I peppered her with familiar questions.
Familiar Faces cross-references Fulton County Jail data with Grady Hospital’s own high-utilizer tracking system, mental health data, and the Atlanta Jail. The federal government is funding the project now — $250,000 a year, for three years — to see if it can drive down costs and reduce the burden on the jail, she said. But she’s learning about where everything goes wrong.
“I think the story for me is that there are so many gaps in the system,” she said, exasperated. “Georgia is 51st in investment in mental health care. We’re working for nothing. This is, by far, the hardest thing I’ve ever done. The traditional systems, they fall through every crack.”
The systems in place to catch high utilizers aren’t working yet. Of the 100 people identified by Familiar Faces, only two had previous contact with Atlanta’s Policing Alternatives and Diversion Initiative, a pre-arrest diversion program, she said.
“We hear people don’t meet criteria a lot for various community, behavioral health, and housing programs,” she said. “Systems in place are so rigid. There needs to be more flexibility, some flexible funding streams are needed to fill the gaps. Also, establishing the Center for Diversion and Services is the key missing infrastructure gap to keep Familiar Faces out of jail. It’s an easy win.”
“We have a plan,” she said. “We’ve had other plans. We need action.”
Harmony’s arrests are absurd. Behold a selection of recent narratives from arrest reports:
Simple assault: “On the listed date and time Ofc. Moore and I were enroute to a call when a black female ran up to the patrol car and stating that she needed help and that she wanted to go to jail. [She] then put her hand in the window and tried to strike Ofc. Moore in the chest with a closed fist, but did not hit him. When Ofc. Moore was taking [her] into custody I went over to assist him and [she] kicked me in the leg stating that she wants to go to jail because she has not slept in a long time. Grady EMS unit 260 responded to the location because [she] was very irate and was talking out of her head.”
Larceny (other): “Victim … stated his two bags were taken with a few items but he confronted [her] because she was wearing some of his clothing items. [He] did not see who took his bags. He stated he left his two bags outside while he entered the Xpress Store and when he came out those bags were gone. Arrestee … admitted to going inside of the bag and putting clothing items on because her clothes displayed human feces on them.”
Public urination/defecation: “Officer Randall … was flagged down by citizens in the area of 236 Forsyth St. the Garnett Office Building. While there, Mr. B. Jones advised that the accused … continues to defecate and urinate on city sidewalks. Officer Randall and Brown have warned and arrested the accused in the past for the same violations. Today Officer Randall contacted the pre arrest diversion along with Grady which the accused … refused saying take me to jail. Officer Randall was left with no other resources because the accused behavior would not change.”
For every one of these encounters, there are probably a handful of police interactions in which cops didn’t bother to arrest Harmony. But they didn’t help her either, because there’s no place to take her except jail. For pre-arrest diversion to work, there has to be a place to divert someone.
Fulton County Superior Court Judge Robert McBurney presented the Familiar Faces project to Fulton County commissioners earlier this month, hoping to convert part of the city jail to a diversion center, a place where people in crisis can be taken in lieu of arrest.
“When 911 is called and an officer responds to a gas station and there’s a gentleman there acting erratically … the only option we have right now is to take that person to jail,” McBurney said. “Now that’s not fair. There’s [the Policing Alternatives and Diversion Initiative], but it doesn’t work 24/7 unfortunately. … PAD is not a cure-all.”
Three out of four times when a cop rolls up on a high utilizer with rap sheets that are an inch thick — someone about to be charged with criminal trespass, public drunkenness — that person gets arrested because there’s no other option, he said.
“They stay longer, they cost more to take care of, and they come back sooner. They’re built-in recidivists.”
“They are superutilizers of our jail,” McBurney said. “They stay longer, they cost more to take care of, and they come back sooner. They’re built-in recidivists.”
It costs about $30,000 a year to keep someone in a jail cell. The example McBurney used from Harris County, Texas’s diversion center showed that the government saved $5.50 for every dollar it spent on its diversion center, simply by keeping people out of jail and the hospital.
People working on this problem in Fulton County have been talking about establishing a diversion center since 2018. I know this because I tried to get one set up at a county-owned property in Summerhill and was summarily castrated by neighborhood political blowback. Even now, with a proposal to build an alternative to jail in a jail, county commissioners are wrestling with how to do so without impeding other priorities — like jailing people.
“It really impacts what [the sheriff] is trying to do with bed space,” Commissioner Natalie Hall said to McBurney, challenging the idea at the text-messaged behest of Sheriff Patrick Labat.
Every single elected official speaking about the subject of the diversion center — a central component to the city and county’s pre-arrest diversion strategy — extolled the virtues of diversion. But I have to ask where the hell the City Council and Board of Commissioners have been for the last three years. None of this is new. It’s just everyone’s last political priority.
After years of inaction, I’m calling bullshit.
Elected leaders want to look like they care about homelessness and poverty while ignoring calls for actual action. In this case, the need to relieve overcrowding at the county jail is a more pressing political problem than a woman sleeping in her own waste on an Atlanta street corner.
“This conversation started way before I got here,” said Commissioner Khadijah Abdur-Rahman. “At some point, we have to move past the conversation. … Business owners every day have to watch a person with a behavioral issue remove their clothes or for whatever reason have an accident in front of them or in their shop.”
Here’s what it’s supposed to look like: A person with psychiatric trouble (or a bystander) reaches out to a government authority — the cops, the paramedics, the state — to get help. Psych paramedics come. If a person in trouble won’t go with them, a social worker comes in to enroll that person remotely in social services and find them some housing. It might be temporary, like a hotel room, but the contact leads quickly to permanent housing with a connection to social services.
We talk about housing first because that’s the policy the system has been designed around. People are not expected to get clean or become compliant with their medications or get a job before being given housing. The housing comes first to help with all the other problems.
When people are easy, this works. But people aren’t always easy. People in crisis, frankly, rarely are.
“At the highest level, maybe we need to make it less hard for people to access our systems,” said my friend Cathryn Marchman, executive director of Partners for Home, Atlanta’s homelessness nonprofit coordinator. “We have to make sure that the opening into these services can’t be this restrictive. More accessible, lower barrier for anyone who walks through the door — hospital, housing system, whatever kind of resource. My general beef is that nonprofits and service provision across the system has to stop cherry-picking who we serve.”
“We have to make sure that the opening into these services can’t be this restrictive.”
Social workers see the same people over and over again. It scrapes away empathy.
“It’s so hard with Grady because they are so overwhelmed,” Marchman said. “In a case like Harmony that is so extreme, I think systems often lose sight of …” She trailed off. “I think they just get jaded. We see behavior as manipulation, as less worthy for access. And certainly, far more difficult and challenging.”
Atlanta is not California. I spent a couple of weeks in Los Angeles a few months ago and San Francisco last year, and I can safely say that there is no equivalent to Skid Row or the Tenderloin in this state. Anyone making that comparison should be ignored.
That said, at the start of the coronavirus pandemic, Atlanta embarked on a massive, federally funded program to scoop up as many people experiencing homelessness as it could and house them. While quite successful, observers say the void has been filled with people on the street who are much harder to serve.
The Department of Behavioral Health and Developmental Disabilities issued 765 housing vouchers for people with severe and persistent mental illnesses in fiscal year 2021, said Maxwell Ruppersburg, the department’s director of supportive housing. Only a few more than 200 people actually got housing, even with money in hand from the voucher, he said.
The state had a budget of about $27.3 million for supportive housing in 2020. It spent $11.9 million. This fiscal year, the state cut the supportive housing budget to $20.6 million. The state has spent $12.9 million. It would have spent the other $8 million if it could have found people to take the money.
Supportive housing costs $15,000 per year, give or take. That’s about 533 people left unserved.
“You hear about waiting lists with other programs,” Ruppersburg said. “We don’t typically have a waitlist. But we have more of a problem with folks receiving vouchers, and then they can’t secure housing. And so the vouchers expire. Ultimately, they get extensions, but at some point they do expire.”
The reason, simply enough, is that few landlords want to rent to someone they fear will trash their building. Housing has been tightening in the Atlanta metro area for the last decade. There’s no shortage of renters without severe psychiatric problems willing to pay full price for an apartment. And there’s no mechanism in the law to force a landlord to rent to someone.
The easy cases are covered, more or less, at least until the eviction moratorium lifts. But the moratorium made landlords far more cautious about whom they will rent to, constraining supply all around.
Georgia’s housing policy rests almost entirely on private accommodation, subject to neighbors waging war on Section 8 at zoning board meetings.
“There is an element of housing discrimination that’s occurring. First, we never know about it individually,” Ruppersburg said. “But it’s fair to believe that that’s happening at a systemic level.”
Some people need more than housing to get healthy.
The state has a legal standard for involuntary commitment, requiring someone to present “a substantial risk of imminent harm to self or others as manifested by recent overt acts or recent expressed threats of violence which present a probability of physical injury to self or to other persons” or appear “to be so unable to care for his/her own physical health and safety as to create an imminently life-endangering crisis.” Colloquially, people working with mental illness on the street refer to this as a 1013, for the form used to commit someone.
When a cop rolls up to a person showing signs of psychiatric distress, they can make an arrest. They can’t 1013 them. Only a doctor, licensed social worker, family or marriage counselor, advanced practice nurse, or physician’s assistant can sign the form. That means a cop has to wait for Grady or the state to send an ambulance. Every time a clinician signs the 1013, they put their professional career on the line to say someone is unwell enough to require crisis stabilization whether that person wants it or not.
The bar, plainly, is very high.
The state legal standard requires hospitalization to be the “least restrictive level of care available for the individual” in order to gain admittance to a state hospital for crisis stabilization.
A hospital can hold someone against their will for crisis stabilization only for five days at a time. After that, either the hospital must obtain a legal order for involuntary treatment or the patient must consent willingly to a longer-term stay; otherwise, the patient walks.
Harmony walks fairly often.
No one with clinical responsibility for Harmony’s care would speak to me on the record about her case, citing privacy laws. The question of admittance has been a bit moot for the last few months, in Harmony’s case, because Georgia Regional Hospital has substantially slowed down its intake of new patients.
“[The Department of Behavioral Health and Developmental Disabilities], along with our health care peers, has been navigating workforce challenges for several months now,” Ruppersburg said. “Our workforce shortages are exacerbated by the additional demands of quarantine units, when needed as a result of the Delta variant, and the increase in demand for behavioral health crisis services nationwide.”
In August 2019, Georgia’s state psychiatric hospital averaged about 15 psychiatric care beds out of service. This August, it lost an average of 99 beds.
A legislative committee has been reviewing Georgia’s civil commitment rules. This spring, the Georgia Behavioral Health Reform and Innovation Commission suggested changes to the state’s legal standards.
“This unreasonably high bar forces families and caregivers to postpone intervention until it appears that tragedy is on the verge of striking, even when it is obvious to all that the individual is in crisis and heading swiftly and inevitably to that point,” the panel wrote. “Forcing people to get worse before they can get help defies copious research demonstrating that the longer severe mental illness remains untreated, the lower the person’s prospects for recovery are. Of course, it is rarely possible to intervene at the very moment that disaster is imminent. More typically, the waiting allows disaster to occur, causing needless human suffering and victimization, and often damning the individual to face serious criminal charges.”
The panel said no legal or constitutional imperative requires “imminence” as a standard. At least 20 states recognize psychiatric deterioration as a good enough reason to hospitalize someone without their consent.
“Under the current law, the potential harms recognized as important enough to warrant intervention are, by definition, those that involve serious physical injury or death,” the panel wrote. “Unfortunately, this disqualifies many individuals in mental health crisis who may not be facing obvious external dangers, but who are powerless due to loss of insight (ability to recognize their own illness and need for treatment) to volunteer for care and protect their minds from harm that could be irreparable in the absence of timely medical aid.”
The state famously warehoused patients for most of the last century in ways that led parents to threaten their children with a trip to Milledgeville if they misbehaved. Today Georgia is under a federal consent order that requires the state to provide housing to people with serious and persistent mental illnesses who meet criteria laid out in the court settlement.
That settlement order defines much of the state treatment that doesn’t start behind prison bars. (For every person with a serious mental illness in a Georgia state mental hospital, five are in prison.) Only recently has the Department of Behavioral Health and Developmental Disabilities begun to reach beyond the agreement to arrange for some new kinds of social services support.
“Some of the systems have been established. For example, they’ve increased the number of [Assertive Community Treatment] teams and intensive case management teams, and they’ve created a housing program for people with severe persistent mental illness,” said Susan Walker Goico, head of Atlanta Legal Aid’s Disability Integration Project.
Most treatment for mental illness doesn’t require hospitalization. There’s a strong legal and medical bias for treating mental health in the least restrictive way possible. At best, that would be in one’s own home on an outpatient basis. Less restrictive than that might be supportive housing or a group home with a therapist, nestled in a neighborhood.
We don’t have enough of any of this.
Whenever someone proposes a supportive care facility or a group home, NIMBYs lose their minds and assemble in force to block it.
“To me, the problem is that the individuals who could benefit from all of these great services have not been reached,” Goico said. “There has not been a real concerted effort to identify people who need supportive housing and connect them to housing and community services that they need. I’m talking about, you know, people who are coming out of prisons and jails, people who are cycling in and out of the emergency department, people who are coming out of Georgia Regional Hospital, public psych hospital, off campus. So, I mean, there are a lot of problems actually making the connection for these people to the services that were created.”
Here’s the thing: In Harmony’s case, as with most of the extreme cases around Atlanta, there’s no shortage of contact. The problem is that it’s often the wrong contact.
A constellation of observers and interested parties has orbited Harmony for the last five months. Tammy Hughes, the social impact director for Central Atlanta Progress, has been demanding action from the city and county. The Atlanta Police Department employs a team of police officers specializing in homeless intervention who have been responding to calls about Harmony. Fulton County’s behavioral health department has been trying to coordinate services with Grady Health System and state hospitals about Harmony’s case for months.
Harmony has a caseworker. Caroline Henderson, a care navigator at the Policing Alternatives and Diversion Initiative, has been regularly visiting Harmony on the street corner for months.
Moki Macias, the initiative’s executive director, like other service providers, politely declined to comment for this story, citing patient privacy.
At least that’s how it’s supposed to work. Roughly 18 percent of all arrests made in the city of Atlanta are divertible, according to figures from PAD. Almost all still end in an arrest, though, because the cops cannot be bothered to engage the program, or there is an objection from the arrestee or a victim, or PAD is tied up with another case.
I helped design PAD while I was working for Central Atlanta Progress, and I’ve counted on its staff more than once to help someone with a tough problem over the years. I have, in fact, stood in Macias’s offices next to the Greyhound station downtown screaming at hospital administrators over the phone because they wouldn’t admit someone who presented herself to me for help. And I have also watched that same person refuse to go with a Grady EMT team after an initial intervention.
Roughly 18 percent of all arrests made in the city of Atlanta are divertible. Almost all still end in an arrest.
The work requires the patience of an anvil. I can’t do it. My fear is that PAD can’t do it either.
By that, I mean that while Atlanta has consistently increased funding for the initiative over the years, it has also consistently expanded PAD’s scope. With each expansion, the public officials responsible for mental health and public safety have laid more of the burden of ameliorating deep social and structural problems on Macias and her staff of 32 administrators, care navigators, and harm reduction specialists.
PAD workers are among the few who go under the bridges and into the woods and behind the gas stations to make actual human connections with people in profound distress. Most of the time, they are responding to a call from Atlanta 311 or police for assistance with a problem that needs a social worker more than a cop.
Between 3,000 and 4,000 people are experiencing homelessness in the city of Atlanta right now. About one-third of them have a serious and persistent mental illness. One-third of them have a serious drug problem. Often those two groups overlap. PAD will go out to about 40 new people on the street in a good month, enrolling a dozen or so into its care.
The city of Atlanta relies on outreach from a handful of caseworkers at Intown Collaborative Ministries to reach chronically homeless people as well. (I have served on that organization’s board since 2016.) The state supplements this outreach with 10 three-person teams through Projects for Assistance in Transition from Homelessness.
“PATH has often been seen as the primary homeless outreach resource in Atlanta when other programs and funding exist for outreach to individuals experiencing homelessness, including individuals with severe mental illness,” Ruppersburg said. “PATH represents an integral part of a larger puzzle.”
PATH teams are also supposed to be in the field, building relationships and connecting people with mental illnesses to housing. In practice, that has diminished substantially since the beginning of the pandemic.
PATH contacted about 20 percent fewer people in fiscal year 2021 than the previous year and enrolled about 10 percent fewer people into case management services, according to figures provided by the Department of Behavioral Health and Developmental Disabilities. Given the 31 percent increase in crisis contacts, those numbers suggest that we’re not imagining things when we look onto the street and find more despair than we used to.
“Each agency has different staffing patterns which may reduce the ability to provide active field work to encampments,” Ruppersburg said. “We have PATH agencies/teams where three-quarters of the staff has been out of office due to Covid during some period during the pandemic. PATH teams have always had collaborative relationships with stakeholders and community partners providing homeless outreach.”
Statewide, about 1,547 people receive psychiatric case management through PATH. Half of the state’s PATH teams serve metro Atlanta. That means PATH serves about six times as many people as the pre-arrest diversion program.
Consider that PAD is on track to increase its caseload by about 100 clients this year. That’s roughly the same number of clients that PATH teams lost in metro Atlanta over the same time.
Far too many people in positions of authority are pointing to PAD as a sign of their police reform credentials and the salvation of serious community problems, while PAD is scrambling to serve the unrelenting avalanche of need around us amid structures that do not work.
I got a call from a Chicago number Thursday night from a woman squatting at a boarded-up house owned by Morehouse College. She had told me a few days earlier that in the course of survival sex work she had been raped repeatedly at the property. I wrote about it. Morehouse responded by sending workers to throw the squatters’ food and clothing in the back of a truck and bulldozing the tent encampment across the street.
All pretensions aside about social justice at the school that Martin Luther King Jr. attended, Morehouse has been acquiring nearby properties for 20 years in a neighborhood that has tumbled into despair and neglect, the better I think for the college to buy up land cheaply. They are not playing nice here.
Morehouse hit the squatters after dark, impeding news cameras and complicating any kind of social services relief. PAD stops taking calls at 7 p.m. Atlanta’s largest shelter, the Gateway Center, stops intake midday, as does Atlanta Mission. Only the Salvation Army shelter might take someone without special dispensations from social services managers, and they restrict people to 10 days of care a year without enrollment in a program.
I made some phone calls and wrangled an after-hours bed at a women’s shelter. But in the time it took to drive across town, she had disappeared.
Such is the system that left Harmony on a street corner. Harmony’s needs are diverse and unusual. The woman I hoped to help Thursday had common problems. Anyone trying to escape a beating from a drunken spouse might run into the same situation I did Thursday night on a rough block in south Atlanta, with everything that works closed for business. A functional system would not depend on personal connections to find help. It would have flexibility. It would be able to adapt.
Now consider how this system will react when 25,000 more people show up looking for help.
I fear what happens as the eviction moratoriums end and the piles of furniture left on sidewalks grow. Atlanta’s poor have long faced housing insecurity. Roughly one out of six households in the city had an eviction filing on their record before the pandemic. In the month after the Supreme Court struck down the federal eviction moratorium in September, landlords in Atlanta’s five-county region filed more than 11,000 evictions, according to the Atlanta Regional Commission. That’s actually fewer than the same month in 2019, but the pace is accelerating.
According to the Atlanta Journal-Constitution, landlords filed about 100,000 evictions during the pandemic, moratorium be damned. Some went through because tenants didn’t really know their rights or because they had violated lease agreements. But courts simply placed many evictions on hold.
About 62 percent of Georgians believe they may be foreclosed on or evicted in the next two months for being behind on payments, according to a U.S. Census Bureau survey conducted last month. It is by far the highest percentage in the United States.
There aren’t actually enough marshals to process all of the evictions that are coming. People will be forced from their homes in fits and spurts. Many residents will look for relief from Georgia’s Department of Community Affairs, which has a $1 billion allocation for emergency rental assistance from the federal government.
After eight months with cash in hand, the department had spent about 9 percent of its money. The federal government is probably going to claw some of the remaining cash back.
Almost none of the people knocking on the Department of Community Affairs’ door have Harmony’s problems. They’ll have different problems. And when those problems don’t neatly fit into existing lanes for help, people will fall through the cracks. The sheer scale of need will turn those cracks into chasms. I can’t tell how many new faces will be competing with Atlanta’s familiar faces for help.
We need to get better at providing assistance to people in need, fast.
Illustrations: Matt Huynh for The Intercept