Reimagining Homelessness & Mental Health: Kerry Morrison on 'Radical Hospitality' & Lessons from Trieste, Italy

Given your professional experience managing the Hollywood Business Improvement District and then, with a Stanton Fellowship from the Durfee Foundation, exploring in-depth how to address at scale mental health and homelessness around the world, let’s begin by your framing what this TPR interview with you should properly be “about.”

Where my passion lies is that I have, throughout a couple decades, not only been inserted in civic life with respect to running a business district, but I was also heavily involved in homeless policy. I was on the LAHSA commission, I was on the United Way Home for Good Task Force, I'm on the HHH Committee, and I have been on a local nonprofit board. I’ve seen issues related to homelessness from ground level up to 35,000 feet.

What I really struggled with as my knowledge about all of this really expanded was that there seemed to be a lack of focus on people with serious mental illness, which is a cohort of our homeless population that was abandoned and doesn't have a voice. These are the people we see huddled barefoot in doorways. I felt called to understand why we have failed this cohort of our humanity, and who's doing it better? Now that I have seen the North Star, I feel that it's my mission and my calling to tell this story because it shows that we can do better, despite our “systems” and institutions that  prevent us from treating people with kindness.

What were you experiencing while leading Hollywood’s BID for two decades that so frustrated you and that led to you to personally refocus your civic mission onto mental illness and homelessness?

I arrived in Hollywood in 1996. Back in those days, homelessness was hardly a blip on the screen. As the city matured and Hollywood's revitalization took hold after I’d been on the job about 10 years, homelessness was becoming more visible in not only Hollywood, but Los Angeles. My board of directors was a traditional business board, and when I raised the issue they would say, “this is not our job, this is the job of government, the job of the faith community,” etc. Because it was so prevalent, I disagreed.

I didn’t tell them that I had begun my own personal journey at that moment to understand who these people are, where do they come from and what is holding them back? In about 2008 I had a personal epiphany and made it my objective to actually start to talk to people that otherwise I would be frightened of. There's one particular person who I still am in relationship to this day that I sat down with on a bus bench and started talking to. It took me several days to even get his name. Through his life, I started to witness the systemic dysfunction of how a person can sit on a bus bench on Hollywood Boulevard covered in excrement for eight months and nobody is taking care of him.

We had a coalition in Hollywood at that time that I helped to form become more active on this particular issue. A turning point came in 2013. Our coalition had a retreat and decided that there was a small cohort of people—we called them the Hollywood Top 14‑—they were the sickest of the sick, the most vulnerable, and the most likely to die without help. We as a small group started to encircle those people and figure out as much information as we could since we were private people without access to any kind of databases.

How often had they interacted with the mental health system? How often had they been picked up for a 5150 hold and taken to the ER and released? We started to try to find their families. Little by little—it took years—we were able to help some of these people permanently get off the street. What we found we had to do in several cases was seek a conservatorship. They were what's referred to as “gravely disabled,” unable to care for themselves on the street. So, you have to make a case to the emergency room to keep them there, make a case to the hospital to keep them for a longer hold, and ultimately make a case to the judge in the mental health court that this person needs to be placed under the care of the public guardian until they are treated, stabilized and can be released into a step-down facility.

Three of the people on the original Hollywood 14 list died on the streets of Hollywood within the first couple of years. That was my foothold. I now had language and case studies. If people said, “that doesn't happen” or “people are cared for” or “conservatorship is a horrible thing,” our response would be that three of these people have died on the streets. This person is so sick they didn't even know that they were having hypothermia. It is inhumane to not take action to help people. I realized that this system is not set up to help these people at all. 

When you say “system,” what do you mean?

I say now, publicly, we have no mental health system. Because if you think about it, a system is an interconnecting set of people, places, institutions, or entities. A system implies that there is  interconnection that you can move through to get to a destination.  Think of how a highway system has on-ramps and off-ramps. If your circulatory system leaked the way our mental health system leaks, we would not be able to live. I would argue that we don't have a mental health system in America.

Who then is or should be responsible for the “system” working?

That is the absolute right question because no one is accountable. From the time that President Kennedy declared that there was going to be a community-based system of care in America and started to shift the responsibility from the federal government to state governments, and state governments eventually shifted responsibility to the counties, it represented a disaggregation of authority and a disaggregation of accountability.

I was surprised to learn a few years ago that there is no state Department of Mental Health. There is no one you can call in the state of California to ask for statistics or outcome measures that would relate to mental health care. Through a series of realignment actions or what also might be described as block grants, each county has tremendous discretion to operate services.

When you don't have authority, you have no accountability. Nobody knows or is willing to describe what you should expect. If you are a parent and your 18-year-old adult child in college has a mental health episode that lands them in the ER, technically, you are not even able to be in communication because they're considered an adult.

Are not families, churches, and community organizations responsible for addressing the “system” failures you cite?

Families feel completely marginalized from the non-system. In the United States, we place a premium on keeping families and friends in the dark about what is happening under the umbrella of HIPAA. It made no sense to us in Hollywood when we were beginning to tackle the Top 14 because our very first instinct was to find out who this person is. We would go on a detective mission and invariably we could find the family and you call somebody that lives three states away. They haven't seen their loved one for 10 years. How can you treat a person without understanding the context that they came from, and that maybe they do have family who are looking for them, who would be willing to help them, who might be willing to even pay for things that could be brought into the system of care?

Churches and neighborhood organizations are doing their best to provide a compassionate place of respite. A great example in Hollywood is Hollywood First Presbyterian Church who has this incredibly kind space called the Lord's Lighthouse that they open up to people. It’s a place for the most vulnerable to walk in and find a place to eat, a place of sanctuary, and a place with a familiar face. There are not enough of those places and the needs of these people are so intense. That is why sometimes the only option for someone is to have them hospitalized and treated for a sustained period of time.

Six years ago, you were awarded a Stanton Fellowship from the Durfee Foundation to spend two years exploring a better way to help people with serious mental illness move from the streets to a safe place to live.  How did you pursue your investigation and did you ultimately find a North Star?

I applied for the fellowship in 2015 using the Hollywood Top 14 as the launching pad for what I learned about the systemic dysfunction in LA County. I didn't know if it was just LA County. My first year, I felt that there would be solutions in the United States. I figured there's going to be some city or county doing this better.

As I talked to people throughout the country, I realized this is an American issue. This is not isolated to LA County. In the second year, I was told about Trieste, Italy. There was a visionary psychiatrist, Dr. Franco Basaglia, who oversaw the closure of the asylum in Trieste. He worked with his teams and city leaders to create a community system of care. When they unlocked the doors of the asylum in 1980, people could stay there if they wanted to, or they could transition into community life.

What does the Community System of Care look like? The city is 230,000 people. They divided it into four quadrants. Each quadrant had a community mental health center. They don't call a clinic because it's not a medical model. It's a whole-person model. Each of these community mental health centers are available 24/7. They are staffed by psychiatrists, psychiatric nurses, social workers, etc.

When you walk into the mental health center, you don't feel like you're walking into a clinic. The clinicians are dressed in plain clothes. There are no lanyards. There are no white jackets. People are freely walking through the space. There's coffee, there's food, and there's hospitality. When we treat people in crisis in LA, we don't treat them in wellness. They have six emergency beds at each of these mental health centers for a city of 230,000 people, and you can walk in without an appointment. You have instantaneous access to people who are willing to work with you and help you. In the Central Hospital serving this entire city, there are six beds in their psychiatric ward. It's an unlocked ward, and there are no restraints used.

You see that the radically different approach to how people are treated actually creates a willingness for people, if they're in having a moment of crisis or if they're feeling unstable, to go to the community mental health center. They know that they're going to be met where they're at. I came back kind of depressed because I had seen this remarkable place, but who was going to listen to me?

About a month later, I got a notice from Trieste that they were having an international conference in November 2017.   I thought I should get some people to go see it with me. I called up Dr. Sherin, who was the head of the LA County Department of Mental Health.  He had been in his job for less than a year and the Board of Supervisors hired him to be a change agent. We got Judge Bianco to come who was the head of the mental health court and Jackie Lacey sent her mental health deputy.  We had Sarah Dusseault representing LAHSA and we had philanthropy. We got LASD to send someone because LA County Jail is the largest mental health institution in the country. We got the mental evaluation unit leaders for the LAPD and the LASD to come. I brought a delegation of 12 back with me to this conference.

I remember looking at the conference proceedings, and almost every country was represented. There was not a single speaker from the United States because the United States has nothing to offer an international mental health conference. That right there was an eye-opener. To Dr. Sherin's credit, he said something like, “now that I’ve seen this, I can't come back and run things the way we been running them. Let's think about how we might cobble together a pilot to take the guiding principles that we see in Italy and apply them into an American context.”

Share what the follow-up and what the next chapter has included?

The next chapter was that Dr. Sherin and LA County entered into partnership with Trieste for an exchange of ideas and people. Dr. Sherin hired a consultant to draft a proposal to do a pilot in Hollywood. Our group did these whiteboard sessions for most of the summer comparing the American mental health system and what happens in Italy. What could we do differently?

He hired Dave Pilon, who is a remarkable psychologist who headed up Mental Health America and a three-year pilot in the ‘90s at the Village in Long Beach. It was a similar thing where you would have a control group who were treated in the traditional clinical-based mental health system, and then the experimental group is the group that they applied whole-person care with a per capita budget. As Dave would say, the problem with the American mental health system is that it is a clinical system. It is attached to a fee-for-service modality, which makes it impossible for you to actually meet the whole person needs of somebody because all you can be reimbursed for are clinical interventions. The pilot, as Dave Pilon envisioned it for Hollywood, was to demonstrate the power of payment reform, which relied upon a per capita budget so that you could provide all the needs that people had without the handcuffs of Medicaid reimbursement.

The other very key component of the pilot was to reduce the documentation burden that people who work in the mental health system have now. We also looked at Hollywood as an ecosystem where this notion of radical hospitality and all the supports for housed and unhoused people living with mental illness would be there. This means cultural amenities, job opportunities, vocational training, and breaking down the social isolation that people with mental illness experience in our communities.

We also imagined some other kinds of interventions that don't exist in Hollywood right now. One would be a psychiatric urgent care center. If you're having a crisis, instead of strapping you to a gurney and taking you to Kaiser ER, a psychiatric urgent care center is a room with soft lights, music, some Lazy Boy rockers, and some snacks. The last thing you want to do for a person in trauma is to create more trauma.

There were all these different kinds of innovations that were baked into the pilot and Dr. Sherin took the proposal to the state committee that oversees the  Mental Health Services Act, Prop 63. They have a bucket of money set aside for innovation. In May 2019, a presentation was made by Dr. Sherin and Dave Pilon, and a few others to the oversight board for MHSA and they approved a five-year, $116 million pilot inspired by the Trieste model for Hollywood.

Have you had an opportunity to return to Trieste? 

When I left my leadership position at the Hollywood BID in 2019, I spent a month in Trieste—I knew I needed a mental break from 22 years of a stressful job in Hollywood. In Trieste they were very gracious, and they allowed me to be embedded in their “system”—I wanted to understand their culture. I was in the hospital ward; I went on home visits with psychiatrists; I sat in on consultations; I visited the social cooperatives where people work; I visited places where people lived.

I became convinced that their “system” was a cultural posture. This horizontal relationship with people was the secret sauce to what they do. It’s not impossible for us to replicate because, as human beings, it's just treating people as equals with kindness.

When I came back that's when I formed the nonprofit and I decided I needed to tell the story.

People are so inspired because it's accessible. It's probably way less expensive than what we're doing right now. I believe a journey of a million miles starts with a couple steps. This is a generational shift that is going to need to happen in America. I have yet to meet anyone who says that our American mental health system works or is worth saving.

May we assume following your return to LA that you later brought mental health professionals from Trieste to take a look at the environment that you had been working in. What did they observe? 

Because of a partnership that LA County entered into with Trieste in September 2018, we brought five Trieste professionals out to see our system. We took them to Skid Row. We also took them to Harbor UCLA hospital in Carson where they have the locked psych ER and a ward with multiple layers of locks and restraints and isolation units. We also took them to the high observation housing at Twin Towers, which is part of LA County Jail and has 5,000 inmates with mental illness—a de facto mental health hospital. In the high observation housing, where people with the most serious mental illness are kept, the individuals are chained to furniture.

We took them also to the Downtown Women's Center. We met with staff there and we felt the positive cultural ethos, and we also went both to The Center in Hollywood and to the mental health clinic on Vine Street in Hollywood. There’s a shocking contrast with Trieste’s commitment to radical hospitality, and the experience of walking into that clinic, which has no windows on the ground floor, and you are immediately met by two armed guards who search your purse or backpack, and then you go to bulletproof glass to seek an appointment. We were all on edge and were not even there for an appointment, what message does that send to people?

When later we all met with Sheila Kuehl for lunch, she asked what they thought of their visit to Los Angeles’ Skid Row. Dr. Mezzina, who actually worked with Dr. Franco Basaglia, said “You may think you closed the asylums in America, but what we experienced today was an open air asylum with invisible walls that make it very difficult to get out.”

The current Mayor of Sacramento, Darrell Steinberg, is proposing a right to shelter in the city as a proposal to provoke a conversation and challenge the public sector to do a better job with their homeless. If you were sitting across the table from Darrell Steinberg talking about his proposal and its history, what would you say?

I appreciate that he is pushing the envelope on these things because, clearly, the status quo is not working. I do believe there should be a right to housing. What I would say is that Sacramento is far less complicated than LA. What I'm hoping that people who are running for office right now in LA do is recognize that housing alone is not going to solve our crisis. The whole issue of untreated mental illness and substance use disorder that we see playing out on our streets right now and often in public situations is a county issue.

Only recently do I think there has been conversation about the fact that the county needs to be aggressively in partnership with cities to meet the needs of people who are left lying on the streets. In Sacramento, you have a much more contiguous city-county relationship, and I think that's going to be a good laboratory to see what he's able to accomplish. The city of LA, I feel, is bearing the brunt right now of trying to build HHH housing, provide Bridge housing, provide tiny homes, and the cities on our periphery are not carrying their weight: Burbank, West Hollywood, Culver City, Beverly Hills, Glendale, you name it.

To advise the mayor of Los Angeles, I would say you are going to have to figure out a way to ensure that there is a regional response to an issue that seems to be concentrated right now in the City of Los Angeles because of legal settlements that we've been subjected to, the city's ability and willingness to pay for resources, and the lack of accountability for neighboring cities to accept their share of this situation.

How should we “frame” our many professional and civic conversations about homelessness? 

We need to have the proper data about who is homeless and what will resolve their homelessness. For some, it's going to be housing. It could be rapid rehousing for the people who are couch surfing or living in their car. For others, it might be permanent supportive housing. For others, it may be a type of housing that I don't think exists in our continuum of housing but that is a higher level of care we need to provide to people with serious mental illness and substance use. It's to recognize that the word homeless is such a broad label for the various cohorts of people who have different needs to resolve their homelessness.

The second thing is that there’s a shortfall of beds that are both treatment and long-term beds for people with serious needs. There's been no clear resolution on who should pay for those beds.

The third thing would be, the public has gotten tired of the lack of accountability that they are sensing. LA County is a fragmented, disaggregated governance structure. It is functioning exactly as it was created to be. With 88 cities and five supervisors who govern a region that is larger than dozens of states in this country, there needs to be a place of accountability and order and specific target numbers so that everyone's held accountable to bring this number down. It's going to require a regional partnership and a partnership with the County to address the needs we've discussed. 

Lastly, elaborate on Heart Forward LA—the organization you’ve created—its mission.

Heart Forward LA is a small nonprofit dedicated to telling the story of how radical hospitality could transform the American mental health system. Of course, that then requires modeling and talking about what radical hospitality looks like. We've been working in several permanent supportive housing communities to model radical hospitality with the residents and to learn about how that how that evolves in a residential community.

We're also working to create a mental health clubhouse in Hollywood. A clubhouse is a place of belonging and purposeful engagement for people living with a mental illness in a community. We don't have any clubhouses in Southern California. There are hundreds throughout the country. It's almost like Trieste within four walls in terms of the culture and posture of a clubhouse.

Finally, my podcast was my pandemic pivot because I thought I was going to be working hard on the LA County pilot and when that was put on hold, I had to keep telling the story. My podcast is devoted to helping people be inspired by the story of Trieste and compare it to our American system. It’s not so much to throw the American system under the bus other than to give people language for asking questions and being hopeful. I've done two seasons of this podcast, and I'm starting the third in late January. The feedback I've gotten from people has been tremendous because it's achieved what I wanted it to achieve: Educating the lay person about how we got here in America. How this has manifested the pain that people experience, but why there's reason to hope we could do better and what is it that we could learn and adapt from the Italian culture.