“I’m coming for you,” barks Todd. Minutes earlier, he was sitting in the psych ED waiting area. A middle-aged white man with a crew cut, reading a newspaper with glasses perched on the end of his nose, he would hardly have looked out of place in my corner diner on Manhattan’s Upper East Side. But his calm demeanor didn’t last long.
Concerned for his well-being after seeing him earlier that day, his psychiatrist at the LAC+USC outpatient clinic had sent him to the emergency room. Now Todd seemed hell-bent on provoking nearly everyone, yelling at doctors to get him the correct meds and ordering the nurse who asked him to change out of his clothes to get him some pants—“man’s pants” because “I’m not a girl.” Todd, forty-seven, had spent more than twenty years behind bars, and now lives on the streets of Los Angeles.
During his intake, he was given two hospital wristbands. When a nurse approaches with scissors to cut off one of the bracelets, Todd jerks his arm away aggressively enough that security officers begin flooding the area. He shouts at the nurse for “coming at” him. An officer asks him to stand and Todd knows exactly what’s coming next. He throws down the newspaper with a “FUCK!” and puts his hands behind his back, the movements practiced and familiar. The officer handcuffs him, then asks him to sit back down. “Just help us out, for my safety and your safety,” he says calmly, patting Todd on his back and directing him toward the chair.
Admitting psychiatrist Dr. McGhee approaches. “What just happened?”
Todd begins to rail. “What happened is these motherfuckers have been fucking with me for over twenty years.” His anger quickly pivots in her direction once she tells him she wants him to “hang out in a seclusion room for a while.” No handcuffs, she reassures him, “but the door will be locked.”
“So now you wanna put me in another cell,” he says. “This is what I fucking get every fucking time.” He stands, taunting the four sheriff’s deputies who guide him away. “Come on, you dick-ass cops! You punk-ass motherfuckers. I come to a fucking hospital, man, and I get treated like I’m back in fucking prison.” Dr. McGhee apologizes, saying that isn’t her intention.
When I ask her a short time later what makes people turn hostile so quickly, she says, “It was brewing already.” Because she had spoken with Todd’s clinic doctor before he arrived, she had a sense of what was coming. Todd has bipolar disorder and is in the midst of a “mixed mania” episode—a combination of depressive and manic symptoms. His doctor worried about what he might do to himself. For some people, mania doesn’t manifest as energetic happiness but as irritability—an “angry kind of driven emotion, lots of energy, no sleep for days, which is what he’s in the middle of,” as Dr. McGhee describes it. He may have been abused in jail, Dr. McGhee says, his traumatic memories triggered by the handcuffs and the seclusion room. All that “emotion and energy biologically driven by the underlying disease and the personality characteristics on top of it is a deadly combination.”
Then Dr. McGhee admits something. “I really love psychosis,” she says. “It’s a strange thing to say, but . . . what makes this job interesting is when people are not entirely connected with reality.” Still, that disconnect adds significant challenges to her efforts. “The number one obstacle for treating people with mental illness is that they [sometimes] have no insight,” she continues, “no ability to be objective about their own behavior and what’s going on. It’s like Alice in Wonderland: Through the Looking Glass. Everything is sort of warped.”
The experience of not knowing you’re psychotic is part and parcel of SMI. It has a medical name, anosognosia, the inability to see an illness in ourselves that is painfully evident to those around us. Many of us are in denial about our flaws, but not knowing you’re psychotic has epic consequences, from inhibiting patients’ cooperation with treatment to leading them to barrel full-steam-ahead on irrational, often perilous journeys. Instead of displaying the instinct for self-preservation that carries most of us through life, people in the throes of SMI with anosognosia often seem to be on a quest for destruction.
By this point I’m not surprised to hear that Dr. McGhee’s perspective is personal as well as professional. Just after she graduated from medical school, her brother was hospitalized and diagnosed with bipolar disorder. “Taking my brother to the hospital was the hardest thing I ever had to do,” she recalls. She had to educate her family about her sibling’s illness. It later propelled her into her job in ED psychiatry. With a sly smile, Dr. McGhee tells me that since most psychiatrists hate the ED, supply and demand means she is fortunate to have a relatively high-paying job that her colleagues avoid. When she was first hired, that salary allowed her to help pay for her brother’s uncovered medical expenses and his college tuition.
Minutes earlier, when Dr. McGhee wrote up the orders for medication, she called for pills that Todd agreed to take before he was handcuffed. Now she considers giving him a shot instead. Injecting the drugs into the muscles of the shoulder or buttocks would get them into the bloodstream—and therefore the brain—faster than pills, but she wants to avoid causing even incidental pain to a man who is already so agitated.
Then, in the midst of her paperwork, a scuffle in the hallway outside the seclusion room draws her back to the area. The door that the doctor ordered locked was never locked, and Todd has reemerged. The security officers ask him to return to the room.
“You guys are gonna lock me in there? You know what’s gonna happen when I come out of there, it’s gonna be a cell extraction. I’m gonna come for her,” he seethes. “I’m letting you know that right now.” Todd turns toward his doctor. “I’m coming for you!” he yells, walking toward Dr. McGhee. A nurse ushers her away as officers surround Todd.
“Code green. Code green,” a nurse calls out, her voice pinched. “Push the panic button!” With that, the hospital announcement system summons the crisis management team. As the officers struggle with Todd, a staffer arrives with a green nylon bag. Todd screams as police and security staff pin him to a table. They wrap a white sheet around his head to prevent him from biting or spitting, which would pose additional risk given his HIV-positive status.
The tight fabric outlines the contours of Todd’s anguished face and a red stain emerges in the left corner of his mouth: a small line of blood is spreading toward his ear. Officers call for a spit mask—a hood made of thin, breathable fabric that will replace the sheet. Dr. McGhee stands at a distance, shaking her head. Todd lies spread-eagle and hooded, secured to the table with wide leather straps around his wrists and ankles.
I watch the Code Green team as they emerge from the room, with a sense of accomplishment as the nurse thanks the deputies with “Good call, officer.” Everyone recognizes that their “victory” over Todd is a Pyrrhic one. No one more than Dr. McGhee. Her half smile belies an awareness of the futility of this victory over an impaired man that might just lead her to tears.
In that moment, I flash on memories of Merle struggling with my parents. As a child, I often watched my family act out a horrific choreography over and over again. Weary from her school day, Merle would lash out at my mother, threatening and sometimes hitting her until my mother called my father home from work. When he arrived, Merle would shift her attention, taunting him with profanities, calling him names and then retreating to the bathroom and locking the door. Only a deeply troubled fifteen-year-old girl would start a fight with a man like my dad—a former boxer with legendary strength. The scene would inevitably end with the bathroom door broken open, my father’s belt in his hands, and my sister in the porcelain tub. He never hit her, to the best of my knowledge, but the belt served to intimidate and subdue her. Once Merle was no longer combative, my mother would rush to her aid, turn on my father, and call him a brute. My dad would leave in a huff. On more than one occasion, he threatened divorce.
The incident with Todd also reminds me of hearing Merle get dragged through the doors of the mental hospital for her second hospitalization, after I’d driven her there under the false pretense of a regular doctor’s appointment. I recall her cries for help when they pulled her through the doors—cries that struck me then as all the more twisted since it was my family’s search for “help” that led me to bring her there in the first place. I know that tying Todd to a bed won’t help his illness and will, in fact, make him more resistant to seeking treatment going forward. Merle’s encounters with forced treatment traumatized her and only increased her resolve to avoid seeing doctors.
After the Code Green team straps Todd down, and after the security and medical teams debrief about the use of restraints (standard policy whenever force is used), Dr. McGhee pulls on blue examination gloves and enters the seclusion room. “I would really like to know if you have any injuries,” she says.
“You did this to me,” Todd fumes through his spit mask. “You’re going to pay for it.”
“Okay,” she replies, nodding, although he can’t see her.
After an hour, during which Todd has been closely watched in the seclusion room, the pills have left him sedated, and Dr. McGhee proceeds with the exam. “I’m going to listen to your heart,” she says. He doesn’t respond.
Many experts adamantly oppose restraints as a barbaric relic of earlier times. “In England, they’ve largely not used restraints for over two hundred years,” explains Elyn Saks, a USC law professor with chronic schizophrenia whose story we’ll hear more about later. “We should be able to do the same things.” Others see restraints as a necessary evil—the only way to ensure patient and staff safety in a dangerous situation—especially in today’s EDs when patients may be intoxicated, they may carry weapons, or their psychosis may make them combative. Forty-seven percent of emergency physicians report having been physically assaulted while at work.1 When a patient like Todd is physically acting out against staff, what choice do they have?
LAC+USC psych ED director Dr. Dias sees today’s use of restraints as characteristically different from that of years past. “Four hundred years ago, people would stay chained up for a lifetime. Nowadays, they stay ‘chained up’ for four hours or less, and in that four-hour window we give them medication that’s meant to calm them down and get them to a state of mind where we can actually release them.” Even so, you couldn’t ask for a more potent symbol of our failure to communicate, connect, and seek collaborative care.
How did Todd, Johanna, Monte, and Merle get ill? In general, why do people develop mental illness? Whether it’s genes, environment, upbringing, or disease, the question has intrigued and perplexed scientists and philosophers alike. The truth is, we don’t know, but it’s increasingly apparent that there’s an interplay of influences in every case, not just a single trigger.
1. Nature and Nurture
Recent science has made clear that biological factors play a major role in the development of SMI. Since the 1970s, we have known that a considerable risk is inherited.2 Since the 1960s, experts found that certain gene variants—as opposed to home environment—heighten the risk by comparing the outcomes of: identical twins who were adopted by parents without psychotic disorders, fraternal twins raised apart, and children adopted into a family where one parent had schizophrenia. Identical twins of people with schizophrenia have about a 50 percent chance of developing the disease, and nonidentical (or dizygotic) twins have a 20 percent chance of both having the disease.3 Although environmental factors can play a role, individuals don’t learn to develop a disease such as schizophrenia. That is, being raised by a nonbiological parent with schizophrenia does not increase someone’s risk of the disease. New studies affirm the role of biology.4
Twenty-first-century advances in genetics such as the Human Genome Project have also shown that genetic risk may account for a substantial likelihood of developing SMI. When we talk about genetic risk, it’s important to understand that you don’t have to inherit a certain gene or piece of DNA; the risk can come from epigenetic mutations in the womb or after birth. More than a hundred areas on the human genome may increase the risk for schizophrenia, and just as many may be responsible for mood disorders such as bipolar disorder and depression.
A large study published in 2018 in the journal Science vividly illustrates the complex biological realities of psychiatric diseases.5 The authors’ review of DNA from more than one million people found that similar risk factors can be found in the presence of many serious psychiatric diseases. In other words, they may not be distinct disease states at all; instead, clinical presentations or symptoms can result from similar genetic vulnerabilities.
As geneticist Ben Neale, PhD, at the Broad Institute of MIT and Harvard explains, “The same common genetic risk landscape is in part shared with basically every other major form of psychopathology [using the current DSM classifications].” This is in contrast to neurological diagnoses like Parkinson’s or Huntington’s disease, each of which has distinct chromosomal abnormalities. Does this speak to our imprecise and insufficient diagnostic categories? Will psychiatric diseases eventually be classified by their genetic alterations and not their symptoms? If such defining biological and genetics discoveries are made, will these diseases cease to be considered psychiatric and instead be called neurological conditions? Or are most psychiatric diseases mainly due to the complex interplay between our psychology and that abstract entity we call the mind, such that SMI will never be traced to distinct biological or physical etiologies, unlike neurological or other brain diseases?
From my own experience, I believe that the most disordered states of mind have a biological basis, meaning that some people are born with or develop, through unknown mechanisms, malfunctioning biological systems in their brains. For some people, the biological malformation may be so strong that disease cannot be avoided. But for most of those vulnerable people, developing destructive diseases is ultimately due to a complex interaction of their biology, experiences, psychology, and culture.
In addition to genetics, inflammation may play a significant role. Inflammation refers to the body’s response to perceived invaders such as bacteria, viruses, or parasites, or, in the case of autoimmune diseases, when the perceived invader is a normal part of the person’s body. In the early twentieth century, scientists found that some cases of insanity resulted from advanced syphilis, a sexually transmitted bacterial infection caused by the spirochete Treponema pallidum. Thirty percent of those who go untreated for more than a decade progress into tertiary syphilis.6 In this severe form of the disease, the infection can infiltrate and damage the brain and nerves in what is called neurosyphilis, leading to symptoms of schizophrenia-like delusions, depression with suicidal intent, personality change and aggressiveness, and dementia-like memory loss. Inspired by the discovery of syphilis-caused insanity—and its eventual cure by penicillin—twentieth-century doctors optimistically looked for other infectious causes of SMI, although no others seemed to have such an undeniable cause and effect, and that thread of research was largely dropped by the mid-1900s.
For the past decade, Dr. Torrey has argued that, on the contrary, we have overlooked several biological influences on SMI. Toxoplasma gondii, a parasite that lives in cats and other felines and can cause the toxoplasmosis infection, affects the dopamine-containing brain cells that are strongly implicated in psychosis. The theory is supported by epidemiological data that shows that adults with psychosis had more contact with cats as children.7 Evidence also suggests that probiotics can repair the bacterial equilibrium in the gut, modulate immune function, and improve symptoms in individuals with schizophrenia.8
One of the most significant breakthroughs in understanding possible biological mechanisms in schizophrenia came in 2016, when Harvard researchers Beth Stevens, PhD, and Steven McCarroll, PhD, determined that certain genes implicated in immune system response seem to be altered in some people with schizophrenia.9 Not only that, they found evidence that an overactive immune response may chip off brain connections in the frontal lobes, aggressively deleting brain cells beyond what typically occurs during the normal process of late-adolescent brain maturation called pruning. (More on this later.)
Although genes, inflammation, infection, and even brain injuries incurred during childbirth or head injuries accumulated on the sports field are all increasingly likely SMI factors,10 developing a psychiatric disease seems to require more than biology; many experts believe there is some sort of trigger for the seed of mental illness to take root. It could be childhood trauma, abnormally high levels of stress, substance abuse, or poverty. And, of course, these things compound. Depression, psychosis, stress, and anxiety disrupt the biological mechanisms of the brain’s emotional, reasoning, and cognitive centers, and the longer they go untreated, the worse their impact. Stress also damages the key structures of the brain and decreases the size of the memory center called the hippocampus.11 The vicious cycle of untreated psychiatric disorders causes more brain dysfunction, which leads to poor decision making, damaged relationships, diminished circumstances, and, you guessed it, more depression, confusion, chaos, and stress.
2. Poverty and Trauma
Poverty, jail, substance abuse, and stress can cause a budding mental illness to develop into its most lethal forms. “Poor people with serious illnesses who don’t have support are very likely to end up either in jails, or rotating in and out of hospitals and homelessness,” researcher and psychiatry professor Jeanne Miranda, PhD, tells me. “The more that patients have social factors impeding their ability to function in the world, the worse their outcomes are going to be, no matter what treatments we give them.” Such factors include access to housing, meaningful work or other activities, community and connection with others, medical care, and nutritious food. “All of those things are essential to form a true treatment for someone, and it’s completely ignored in our system, for the most part,” Dr. Miranda says. In her experience, one of the most effective ways to improve the lives of people with SMI is to ensure that one single person in the mental health system sticks by them for the long haul, rather than bouncing them between offices and agencies and caregivers. That is true of all ailments, but perhaps more so with SMI than with an illness like heart disease in which there are curative steps, such as arterial bypass surgery, that can help even in advanced stages of the disease. An illness such as schizophrenia has no such end-stage cure.
Mental illness can lead to poverty, but does poverty cause mental illness? Nothing is straightforward when it comes to SMI, but Jeffrey Draine, PhD, and his coauthors of the paper “Role of Social Disadvantage in Crime, Joblessness, and Homelessness among Persons with Serious Mental Illness” explain the common downward spiral this way: “If persons with mental illness are not poor to begin with they are likely to become poor, and poverty factors become salient in explaining common outcomes such as quality of life, social and occupational functioning, general health, and psychiatric symptoms.” The bottom line is that socioeconomic stress is correlated with and contributes to the development of many categories of mental illness.12
3. Substance Abuse
Mental illness and substance abuse feed each other until you have a conflagration that is much more toxic than the sum of its parts. If having a mental illness is like living in a house with a smoldering fire in the basement, substance abuse is like hurling in live grenades from the second floor. It makes everything exponentially worse.
Dr. Dixon pioneered findings in the area of what are now referred to as co-occurring diagnoses (meaning SMI combined with a substance use disorder [SUD]). She began studying this when we were both residents in 1989, confirming “the alarmingly high rate of substance abuse” among people with schizophrenia.13 Since then, significant research has called into question the false binary between SMI and SUD. At least one quarter of people struggling with homelessness also have an SMI,14 and within that subset, as many as two thirds also have a primary substance use disorder or other chronic health condition.
Co-occurring SUDs are also found in about one quarter of all individuals with SMI,15 and the catalytic factor isn’t always hard drugs bought on seedy street corners. I once treated a brilliant student from an affluent family attending an Ivy League college who, after spending her junior semester abroad in Amsterdam smoking as much weed as she could, developed the symptoms of schizophrenia. Her intense exposure to marijuana had opened a window on psychosis that I couldn’t close. She was no longer able to handle the most basic college courses and had to drop out of school. She became paranoid, her thoughts disorganized, and she felt increasingly isolated from friends. Ultimately, after a decade of medication and therapy, her condition improved, and she was able to return to college to earn her degree. Medicine, psychotherapy, and avoidance of all substances of abuse enabled her to restore her sanity. She was extremely fortunate to have had well-heeled parents with plenty of resources to draw upon to help her recover; many don’t.
A year after the ED fiasco, Todd is back in skid row, the neighborhood that he’s called home since he arrived here from Illinois in 1989. Todd has rejoined the 53,195 homeless people in Los Angeles County and 31,516 in the city of Los Angeles,16 at least 27 percent of whom are believed to have an SMI.
Talking over wailing police sirens and the rumble of a jackhammer gnawing away at the pavement, Todd plays tour guide, pointing out shelters, free clinics, and other social service facilities. On San Pedro Street, people congregate outside the Union Rescue Mission, which helps “men, women, and children escape the streets of skid row through food, shelter, education, counseling, and long-term recovery programs,” its façade built of cement blocks painted aqua. A man perches atop a large duffel bag, elbows on his knees. A slender young woman in a ponytail and a gray hoodie sits on a milk crate beside a shopping cart, a “tall boy” beer can on the sidewalk at her feet. Men in wheelchairs loiter outside a long chain of tents pitched on the sidewalk. A woman sells used clothing laid out in piles on a tarp. A twenty-something woman with bleached blond hair in jeans and a spaghetti-strap tank top tosses something small, it’s unclear what, into the air, then traipses away, her bare feet blackened with dirt. Above the row of shopping carts, suitcases, and other baggage covered with blankets and tarps hovers a red heart-shaped balloon on a string. Todd occasionally waves hi or asks people how they are doing today.
Todd mentions a woman he knows—“a little sweetheart” who “has a lot of mental health issues.” Although a social service organization helped her find housing, she couldn’t stay. “She hated living inside so much that she gave it up to be homeless,” he explains. “There are documentaries regarding that issue—about people who’ve been homeless for so many years they prefer to be homeless. Someone like that has got to have mental health issues—when you can’t live indoors for whatever reason.”
In the decade and a half that Todd has spent on skid row, he’s become an expert on the available services: where to get a free shower, wash clothing for $1.25, see a doctor, take an art or life-skills coping class, get counseling, or exchange one dirty needle for five clean ones. That last service might have helped him had he availed himself of it earlier in life: “I caught HIV from shooting drugs,” he says. “I was shooting drugs behind somebody that had it and never told me, and I ended up catching it.” He explains this with resignation, just a tinge of bitterness showing in the way he sets his jaw. Todd was diagnosed in 2005 when he was hospitalized for pneumonia. “Who gets pneumonia in July? In California, eighty, ninety, one hundred degrees? Pneumonia’s one of the biggest killers for people with HIV and AIDS,” Todd says. “So, that’s why I always wear coats. It could be seventy, eighty degrees out, I got a coat on, you know, ’cause I’m afraid of catching pneumonia.”
Now, Todd is prescribed a daily cocktail of HIV medications as well as antipsychotics and mood stabilizers. For a while, he says, doctors were “guinea-pigging me,” trying out different combinations of drugs. But over time they found “a nice mellow pattern, I guess, of psychiatric medications to keep me calm. I mean, sure, they keep me calm to a certain extent. They stop the thoughts.” His thoughts “jump around” a lot so that he “can’t remember short things. I mean, my short-term memory is shot. I could take my medication, and then twenty minutes from now I’ll forget that I took my medication, and I’ll take more medication. You know what I mean? That’s why it’s good to have somebody—anybody—to go, ‘Wait a minute. You just took your medication, dummy.’”
Monthly visits with a psychiatrist at the outpatient clinic of the LAC+USC Medical Center help keep Todd on track, somewhat. At the very least, the appointments allow him to vent. “Well, how are you doing?” the psychiatrist begins, on a visit that I attend. The date is February 1.
“Today’s a fucked-up day,” Todd replies. “Today’s the anniversary of Maria’s death. Remember my girlfriend?”
“Yes.”
“The one they tried”—Todd stumbles over his words—“they tried charging me with her murder?”
“Yes. They have a lot to learn. That’s ridiculous,” says the psychiatrist. “I’m sorry. I really am.”
Together, the two of them do the math and realize it’s been four years since Maria overdosed while she and Todd were living together in a single room occupancy (SRO) hotel nearby. “You’re right. Four years. Oh, my God. Time flies when you’re having fun, huh?”
Todd tells his psychiatrist the latest news in his seemingly endless quest to secure a decent apartment. For several months, he has been working with LAMP (now called the People Concern), a nonprofit that helps people who are homeless. He hopes that housing support will afford him the opportunity to save a little money, so he can get his life back on track. “Subsidized housing is great. Everybody thinks we want a free ride. No, we don’t want a free ride. We just want a step up. You know what I mean?”
But the stress of this protracted process is particularly overwhelming for Todd. “They keep telling me one thing and another. I feel like a Ping-Pong ball. It’s so damned fuckin’ hard, and I get pissed off,” he says. The leather jacket he’s wearing, despite the warm office, squeaks as he shifts in his chair. “It depresses me. And, you know, a lot of shit goes in my head when I get depressed, and the next thing you know”—he interrupts himself with a chuckle and raises his eyebrows—“the sheriffs are being called.” His smile reveals a mix of humor and resignation. “This whole trying-to-do-things-normal is frustrating the hell out of me. Because I’m not normal. The government, the system, everybody wants to keep you down. If you’re poor, if you’re crazy, they want to keep you down, or lock you up. I mean, how many years have I been with Mental Health? Forty-three years and they still haven’t fixed me.”
Todd has been struggling to eat on the $60 that’s left of his $960 monthly disability check after he pays his rent at the SRO where he’s managed to find a room this month. Food banks keep him going, but despite his clear intelligence, even organizing the simple tasks necessary to feed himself become a challenge. “I love cereal, so I eat cereal all day long,” he tells his psychiatrist. “I have an itty-bitty refrigerator, so I only can buy these milks like this,” he says, showing her with his hands. “They’re $2, and I only like Ralphs milk, so I have to go all the way to Ralphs to get it. And I gotta get, like, one of those every day. It costs $2.19. I go get one, even if I have to, like, go borrow a couple dollars or something, I get one of those ’cause I love cereal.” Then, like a little kid proud of mastering some new stunt, he tells her excitedly about how this morning he used a trick he’d learned in prison: substituting yogurt for milk in his cereal. “I got a thing of yogurt from the food bank. I bought a cantaloupe. So I had cantaloupe slices I put in the yogurt, and orange I put in the yogurt, and . . .” He racks his brain to remember. “Banana! I put it in the yogurt. I got a big ol’ bowl of Cap’n Crunch.” He laughs. “And I put the yogurt with all that fruit instead of milk.”
“Oh, good!” says his doctor, encouragingly.
“Oh, man, that was good,” Todd agrees, smiling.
“That’s very creative.”
Then, in a flash, he leans over, hand over his eyes, and circles back to Maria. “I was thinking maybe later, I don’t know . . . I’m not getting drunk today. I got a couple of bucks. I could go buy a beer and go pour it in our favorite spot.” He sits with the idea, deep creases across his forehead. “Because I don’t know where she’s buried.”
“Oh, that’s hard.”
“I heard they burned her body. You know, she didn’t have any relatives.” He pauses, eyes wet. “I loved that girl.” He nods, lips pursed, eyes far away.
“You did,” says his psychiatrist. “I remember your coming together.”
“We’d come together like shadows.”
After his appointment, Todd stands on the sidewalk in a low-rent business district on the outskirts of skid row. He explains that he no longer has a girlfriend. “I have this fear in my head that being with somebody is . . . you know, I’m jeopardizing their life.” But his “friends out on the streets” mean a lot to him. His buddy Ron, for example, a veteran whom Todd describes lovingly as “a nerd—legitimately a nerd. All he likes doing is reading. That’s all he does is read, read, read, read.” Since Ron lost his library card, he and Todd alternate days using Todd’s. “Today’s his day.” Friendships like these help keep him connected and, in some ways, he is much better off than his neighbors. “When it becomes okay in your mind to sleep on the ground next to dried-up urine or dried-up feces—human waste . . . when that’s okay—you know you’ve snapped. You’ve gone too far over the cusp of reality. I was there once,” he concedes. “It was prison that pulled me back out of it.”
Todd was in his twenties the first time he went to prison. (He never told me why he was incarcerated and always changed the subject whenever I brought it up.) Spending two decades “in an eight-by-twelve cell” is part of why he now prefers to be outside. “I really don’t mind living on the streets, except for having to find a shower or something—usually a bathroom. ’Cause I used to live on the streets and dig through garbage cans and all that stuff, and I was happy.” But his HIV status, high viral load, and low T-cell count leave him susceptible to infection. “Because of my medical issues, I need to live indoors.”
Standing on a street corner across from a row of discount stores selling caps, dishes, luggage, and liquor store supplies, Todd explains the interminable cycle. “I go back and forth between fighting and running, fighting and running, fighting and running. Right now, I’m fighting again, probably because of my medical situation. I don’t want to die on the streets.” He pauses, then shrugs. “A lot of people out here suffer from either drug addiction or mental health issues and that’s why they’re down here.” His voice cracks. “It’s sad—it’s really sad,” he says, the tears and anger welling up. “And I suffer from it, and these people suffer from it, and there ain’t no help nowhere! We just keep going around in circles, and we get nothing. It’s just sad.”
Three months later, Todd’s stress boils over after a phone call with his LAMP housing counselor, Steve Mitchell, who has been working for months on his behalf. Todd is still waiting for safe, affordable housing to come through. Finally, Mitchell tells him that LAMP has not only received the necessary payment voucher but also found an available unit—but Todd can’t move in for a few more days. “It makes no sense to me, man,” Todd says as he hangs up the phone. “Leave someone sleeping on the goddamned sidewalk when he’s got a fucking apartment.”
With a high-pitched wail, he hurls his precious phone onto the pavement, pieces of it flying. “I’ve heard the same thing three fucking times,” he moans, pacing, arms flailing. “Roof! Fucking homeless on the fucking sidewalk when he’s got a goddamned, a fucking roof.” His words come out choked and garbled. “He’s got a fucking roof. And he can’t get in it. He fucking can’t get in it.” Todd folds at the waist, doubled over, fists pounding at the air. His sunglasses drop to the ground. “I don’t understand it,” he yells, struggling to pick up his belongings and shove them into his pockets. “I don’t fucking understand it. Motherfuckers!”
The next day, Mitchell comes through, and Todd turns a key in the door to his new apartment—a clean, well-kept studio, complete with a couch, a bed, a kitchenette, and a private bathroom tiled in bright teal. “It’s nice,” says Mitchell as the door swings open.
“It’s a big one! Yay!” Todd says, wearing a huge smile. He laughs as he walks over to the wide picture window overlooking the street, then begins to rock slightly, back and forth.
“Congratulations,” says Mitchell, smiling.
When Todd turns around it’s clear that he’s weeping. He sits down on the window ledge. “Four years, man,” he says, crying, shaking his head, smiling at Mitchell. “Four years.” He wipes his eyes, but tears keep coming. “Thank you, Steve. Thank you.”
Two years later, I find Todd’s name on a roster of Los Angeles County jail arrests. He appears at his court hearing in navy blue scrubs printed with white letters: LA COUNTY JAIL. Limping, wearing a neck brace, and using a walker, he makes his way to the chair beside the public defender, who asks the judge for Todd to be released on his own recognizance “on compassionate grounds” because of his declining T-cell count and the fact that his offense (a small hand-to-hand drug sale) was nonviolent. Because of Todd’s previous conviction, the judge denies the request. It takes three months for Todd to accumulate enough in disability checks to post the $1,000 bail necessary to secure his release.
Then Todd loses the apartment, the best home he’s had in decades. As Mitchell explains it to me, Todd had put down a deposit on a new place, but it never materialized. Instead the money disappeared. “A scam,” says Mitchell. In the meantime, Todd told the building management he was leaving, so they gave his place to someone else. Like most things with Todd, the story doesn’t make complete sense. For me, it’s confusing; for Todd, the world must seem completely illogical. The last time I saw Todd was outside a Starbucks near skid row, near his run-down SRO. The LA sun was hot, yet Todd wore a heavy corduroy jacket and drank hot coffee to stay warm. Hunched over, thin and weak and fifty-five (the age Merle died), he said he has liver and kidney cancer and is skin-popping heroin for the pain. He smiles, thanks me for the coffee, and gives no sign that he’s given up.