(1-11-19) From My Files Friday: Whenever forecasters predict snow, I think about those who are homeless, psychotic and abandoned. Stories about hypothermia deaths always anger me, but few did as much as this death that I first noted in 2010. Are any of us naive enough to believe that such preventible tragedies will not happen again this winter in the most prosperous nation in the world?

WHO IS TO BLAME FOR THIS DEATH?

The residents of Morrisville, Pa., got an insider look at our troubled mental health care system. Paulette Wilkie, a homeless woman with a long history of schizophrenia, was found dead from exposure. The 56 year-old woman’s body was discovered behind Ben’s Deli, a sandwich shop that she frequented.

Temperatures the night before had dropped into the mid 20s. But that was not cold enough to trigger the county’s emergency homeless plan. Temperatures must sink to 20 degrees or below for two consecutive days before teams can be dispatched to try to persuade homeless persons to come indoors.

Reporter Ben Finley, writing in the Bucks County Courier Times, noted that people who knew Wilkie said she likely would not have gone into a shelter anyway. The owner of Ben’s Deli said Wilkie refused help from people concerned about her safety and health.

Wilkie’s father said his daughter had been in-and-out of a local community mental health center for more than 20 years. She’d lived in a group home until last year. Another resident said Wilkie was asked to leave the home after she stopped taking her medication. Wilkie’s father said his daughter did not like to take her medication.

He said mental health officials told him that she couldn’t move back into the group home until she “got back on the medication and was clean.” Her father added that his daughter had been hospitalized about a month ago and that he probably should have moved her into his house when she was discharged, but he was concerned about doing that since she was not taking her anti-psychotic pills.

The owners of Anthony’s Pizza and Ben’s Deli said Wilkie was a regular fixture on their street. Everyone knew her and knew that she had a mental disorder. She always wore the same parka, hood lined with fur, even in the summertime. Shortly before her death, the two business owners said they noticed a sharp decline in her mental health. She was losing weight and had stopped bathing.

On the weekend when she died, Wilkie had gone into Anthony’s Pizza, but the store’s owner had asked her to leave because she smelled very bad and customers were exiting the store.

“My wife was here and she said (Wilkie) is going to freeze out there,” the owner told the newspaper.

Wilkie was last seen sitting on a picnic table behind the deli with her socks and shoes off, smoking a cigarette.

While I do not have inside information on Wilkie’s death, she is not the first person with mental illness to freeze to death on our streets.

Could her death have been prevented? Absolutely.

The first question we need to ask is why was this woman homeless?

I’ve heard people say that homeless persons prefer living under the stars rather than being inside. I’ve found this rather romantic notion to be hogwash. Even the sickest homeless person I’ve met doing my research has wanted a warm and safe place to sleep at night. Unfortunately, overnight shelters often are dangerous or have no vacancies. Other housing programs are rule oriented and restrictive.

The solution here is Housing First.

Housing First does not require a homeless person to take medication or to stop using drugs/alcohol before he/she moves into an apartment. Instead, that individual is given shelter because no one can get better mentally or physically if he/she is sleeping on the street.

Most Housing First programs require tenants to pay a percentage of their income for rent. You earn zero, you pay zero. Tenants also are required to meet with a treatment team once a month. In many cases, the team is able to establish a relationship with the tenant. Team members work with tenants to get them the services that they need to control the symptoms of their mental disorders and/or beat their addictions. They provide social interactions and oftentimes much needed friendship.

In addition to Housing First, communities have had great success with Assertive Community Treatment teams, composed of specialists who visit persons who are homeless. Oftentimes, these teams have doctors, therapists, peer-to-peer specialists, and job and addiction counselors on them. Their job is to try to get homeless, psychotic persons off the streets and into shelter and services. The most successful form a personal bond with their clients.

Those are just two programs that can help persons who are homeless and have a mental disorder.

What if there are no Housing First facilities or ACT teams?

There are other alternatives to allowing someone with a brain disorder to freeze to death on our streets. The most obvious is involuntary commitment to a crisis care center or hospital. But that alternative often is unavailable. Waiting lists are long at many crisis care centers, many hospitals don’t want to accept someone who is psychotic and then there is the hurdle of “danger to self or others” that often is used as an excuse to not help someone.

No one can predict dangerous behavior and waiting until someone becomes dangerous often results in an arrest or worse.

Wilkie had a long history of schizophrenia.

The people who encountered her noticed her mental condition was deteriorating. The temperature was dropping below freezing and she was last seen sitting on a park bench with her socks and shoes off. Yet, it’s unlikely that she would have met the dangerous to self or others criteria. Of course, involuntarily commitment is only useful if a person actually gets meaningful medical care and social services after they are committed. Ordering someone to a hospital for a shot of Haldol and then being shoved out the door rarely helps anyone permanently recover – and might cause even more harm.

Another evidence based practice that might have saved Wilkie’s life is Assisted Outpatient Treatment. In its simplest form, AOT laws permit a judge to order an ill person to accept treatment if they meet strict criteria. AOT has proven to help persons with serious mental illnesses but providing the continuity of care that is needed to get the greatest benefit from AOT is problematic.

Wilkie’s father was quoted saying that “someone dropped the ball.”

That’s a bit too easy of an excuse for me.

I suspect community mental health officials felt their hands were tied. Wilkie’s illness had taken over her mind. She had refused to take medication that clearly helped her. Even her father said he was afraid to take her into his home when she was off her medication. The police said she wasn’t a threat. She wasn’t dangerous. And based on her own psychotic actions, Wilkie didn’t want anyone to help her.

So who, if anyone, is to blame? Mental health professionals? Her family? The police? Civil rights laws that protected her right to die with her rights on? Wilkie herself?

How about all of us – for not demanding that individuals such as Wilkie – at a minimum – are offered a safe place to live without conditions?

When did we decide as a society that it’s acceptable to walk by a woman with a serious mental disorder who is sitting on a park bench not wearing any shoes or socks in freezing temperatures and say, “Oh well, it’s none of my concern?”