Dr. Chad Koyanagi is the only street psychiatrist in Hawaii today who goes out day after day, sometimes into the night, to bus stops and the sidewalk hangouts of Hawaii’s most vulnerable homeless — the severely mentally ill.

Koyanagi has been reaching out for decades to tattered, often foul-smelling vagrants many of us cross the street to avoid.

“I feel for them,” he says. “They are the most disenfranchised, severely ill people that I can think of.”

His goal is to gain the trust of the homeless people with mental illness, some of whom scream obscenities at pedestrians passing by or urinate in broad daylight in front of Chinatown shops.

He never gives up trying to persuade them to agree to take medication when their chaotic minds see no need for medicine; they are so ill they think they are perfectly fine. The name for their disorder is anosognosia, the inability of a person to recognize his or her condition — a common feature of schizophrenia and bi-polar disorder.

Families of the mentally ill are frustratingly familiar with this particular form of cluelessness.

Koyanagi, 48, grew up in the Salt Lake area of Oahu, the son of a firefighter and a secretary at the University of Hawaii. After McKinley High School, he graduated from Harvard and received his medical degree from the John A. Burns School of Medicine at UH.

He said he never intended to be a street psychiatrist. But after medical school when he started working at Safe Haven, a residential home for homeless mentally ill, “I discovered my love for this kind of work.”

He thinks it is unusual to find a Japanese-American like him doing intense psychiatric outreach to homeless schizophrenics because of what he describes a sense of shame about mental illness that persists among people of Japanese ancestry.

Last year, working with a street team of outreach workers from the Institute for Human Services, Koyanagi succeeded in treating 20 homeless people who agreed to accept his care on an outpatient basis with monthly injections of Invega Sustenna. It is a drug that has been used to successfully stabilize people suffering from schizophrenia.

The street team’s goal is to get those with mental illness collected enough to agree to go into housing. But once they receive housing, there is often not enough funding for needed service providers to make sure they continue to take their medication and handle the many different responsibilities of renting an apartment.

“If they are not getting enough wrap-around services, many of them go back out on the streets. It happens a lot,” he says.

When I walked with Koyanagi in Waikiki with an outreach team from IHS, we stopped to talk to a homeless Vietnam veteran named Scott C. Fox. Fox told us he has been kicked out of three different “Housing First” subsidized apartments because he was drinking and inviting other homeless to stay with him in the apartments, which he says increased his drinking and partying.

“It is hard to say no when they ask to stay overnight considering I know what it is like for them out on the streets,” Fox said.

IHS community relations director Kimo Carvalho says that zig-zagging from housing back to homelessness to housing is an ongoing problem.

“The state and the city have to step up to prevent people from falling back into homelessness,” he said. “The money now is mostly on front-end services to move people into housing but there’s not enough funding for case managers and other professionals to keep them in housing. When formerly homeless people fall out of housing it become increasingly difficult to get them back in again.”

In the past, the state and city were focused more on the so-called “low hanging fruit,” homeless families with children who were eager for housing. But public policy is slowly turning toward providing more help for drug addicted and mentally ill people living on the streets who year after year end up costing the public millions of dollars with repeated visits to hospital emergency rooms, and multiple hospitalizations and incarcerations.

In 2011, Queens Medical Center treated nearly 7,000 homeless with mental illness; by 2016, the number had soared to 16,000. Queens spokesman Cedric Yamanaka says the hospital has had to shoulder nearly $10 million in unreimbursed funds annually for their inpatient and outpatient treatment.

The state corrections department says on any day 12 to 15 percent of the inmate population statewide includes people diagnosed with serious and persistent mental Illness.

The Mayor’s current budget proposal has a request for $400,000 to put more psychiatrists like Koyanagi on the streets. The funding would also allow the hiring of more lawyers and psychiatrists to urge state family court to intervene to require treatment for severely ill and mentally challenged homeless.

“Mayor Caldwell really wants to go after this tough group. They are in bad shape,” says  Marc Alexander, city housing director. “They really need our help. These people are not about to make appointments themselves to go and see a doctor.”

Hawaii is one of 46 states with an assisted treatment law to allow courts to mandate mental health treatment for people too ill to care for themselves. But the law has rarely been used since it was enacted in 2014.

Diane Haar is the first attorney in Hawaii to use the new law to petition the court to order treatment for a severely ill homeless woman. Haar lost the case. She believes that the courts then and now continue to be uncomfortable with the notion of medicating a person against their will even when person is too mentally ill to take care of themselves.

She says another reason that the assisted treatment law is rarely used is because it is expensive for homeless care agencies such as IHS to hire the lawyers and psychiatrists needed to petition a family court judge to invoke orders for involuntary care.

Deputy Public Defender Phyllis Hironaka is currently defending a schizophrenic homeless woman against a petition brought to the court by IHS to allow Koyanagi to treat the woman’s illness. Hironaka say her client doesn’t want treatment and that as the woman’s public defender, it is her job to protect her client’s civil liberties and personal desires even when the client is suffering from schizophrenia.

Koyanagi says there needs to be a better understanding among defense attorneys that the needs of the homeless and the community are not served when people who can’t take care of themselves are allowed to remain untreated living on the streets.

The state is stepping up to support more psychiatric care on the streets.

State homeless coordinator Scott Morishige says the Department of Health now spends $800,000 a year for homeless outreach for the severely mental ill, as well as $500,000 in funding for an intensive case management pilot program to help the mentally ill homeless who have frequent interaction with law enforcement and hospitals. He says the pilot program will also include pharmaceutical and psychiatric services.

Koyanagi says when he is driving, he sees homeless people who are very ill all over Oahu.

“It can be very discouraging. The homeless problem is so enormous,” he says. “Many people are getting housing but there are people still on the streets who are more complex and harder to house.”

In his line of work, he says, “You have to be patient, you have to be assertive and to never give up waiting for the opportunity to be there when someone decides they are finally ready to accept medical treatment. It can happen when a homeless person once again gets arrested or when a family member intervenes or when someone decides they simply can no longer bear the struggle.”

In the meantime, he takes small satisfactions from his work such as hearing a psychotic woman he has been trying to help for years call out “hey, Dr. Koyanagi,” as he passes by on Fort Street Mall.

“It is such an experience to hear from someone so downtrodden, so mentally disturbed, to know she trusts me and holds me in regard. It is an amazing feeling.”

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