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In early December 2019, Alice Carter, a transgender woman who had experienced homelessness, met with the clinical director of Street Sense Media, Lissa Ramsepaul, and told her she wanted to “do some different things” to change her life. Carter was a ubiquitous and beloved figure in D.C., with an “infectious smile” and a love for poetry and music. She even performed her poetry onstage at Busboys and Poets. 

But for years, Carter struggled with both a mental health and substance use disorder, and was repeatedly incarcerated. She had also recently told a nurse at Community Connections, an organization that provides behavioral health care and primary care services to people with substance use disorders and mental illnesses, that she was drinking four pints of alcohol a day and using cocaine, PCP, and K2. 

On Dec. 17, soon after her final meeting with Ramsepaul, passersby and Metropolitan Police Department officers found Carter unconscious in front of a McDonald’s on 17th Street NW. She was transported to Howard University Hospital, where she was pronounced dead. Her death certificate lists her cause of death as alcohol intoxication; she was less than 10 days from turning 36. 

These details about Carter’s life, her treatment in D.C., and the circumstances that led to her death—all based on medical records and accounts by the people who knew and worked with her—are included in a new case study conducted by Street Sense Media for the D.C. Auditor. The report examines the public and private institutions that shaped Carter’s life in an attempt to “put a human face” on substance use disorders and incarceration, according to D.C. Auditor Kathleen Patterson.

The report is a rare and somewhat unprecedented look at the intimate details of life that officials often decline to provide—or are legally barred from providing—to the press. But Clara Hendrickson, the reporter who wrote the case study, says telling Carter’s story in this way provides an opportunity for the city to better support people experiencing homelessness. (Carter’s records come from Carter’s next-of-kin, her mother, who gave Street Sense Media permission to review records she obtained from D.C. agencies and community service providers. The Court Services and Offender Supervision Agency declined to provide access to their reports. The agency didn’t respond to City Paper’s request for comment.)

“Not everyone has a case study written about them, but every death has a story that the city is missing out on learning from,” Hendrickson says. “Each instance of someone experiencing homelessness dying in D.C. is a chance for us to learn how to do better.”

Carter was one of at least 81 people experiencing homelessness who died in 2019, and throughout her life, she engaged with a number of organizations in D.C. geared toward people who face housing, substance use, mental health, and other issues. 

Patterson writes that, by telling Carter’s story, “after hundreds of professionals tried to help her with housing, medical care, and legal support, we might help others who struggle as she did.”

The revelations in Street Sense Media’s report and in a companion report for the D.C. Auditor authored by the Council for Court Excellence are staggering. Looking specifically at the years 2015 through 2018—the length of Mayor Muriel Bowser’s first term—the groups found that the D.C. government failed to provide continuous care to people with substance use disorders before, during, and after incarceration, with just over 1 percent of incarcerated people receiving full care continuity, out of more than 4,600 cases. 

The 42-page case study from Street Sense Media explores Carter’s numerous incarcerations and overdoses, diagnosis of schizoaffective disorder and polysubstance dependence, and chronic homelessness as she weaved in and out of substance use and psychiatric treatment programs. At times, Carter was involuntarily committed to treatment programs. Throughout, those who knew her also remember her smile and creativity. She routinely wrote poetry published in Street Sense

 “I think that’s really what she would want to be remembered for, is her art,” Colleen Cosgriff, a former case manager at Street Sense Media, says in the case study. 

Drawing from Carter’s life, the companion report concludes that MPD officers should arrest fewer people experiencing mental health crises, asks D.C.’s Department of Corrections to adopt substance use disorder screening tools as well as intervention services for returning citizens who spent a short amount of time in jail, and calls on the D.C. Council to fund a pilot program to keep at least one substance use disorder service provider open 24/7. 

The idea to look more fully at Carter’s life came

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after Street Sense Media CEO Brian Carome wrote about her death in the Washington Post, Patterson says. Earlier this year, Street Sense Media, helmed by Hendrickson, began sorting through countless records provided by Carter’s mother to piece together years of Carter’s life. 

For many of those who knew Carter, reading the case study meant witnessing the entirety of Carter’s struggles and pain. “I felt grief all over again,” Ramsepaul tells City Paper. But for Ramsepaul and the many advocates who continue to work with similar populations, the case study also renews their continued push for change in the services that help people experiencing homelessness, incarceration, and behavioral health disorders. 

“This report is meaningless without action,” Carome says. “There are a lot of other Alices out there.” 

The report points out that almost every level of the system failed Carter in some way, failures that include city officials failing to afford Carter basic dignity. On several occasions throughout her life, she was incarcerated with male inmates, despite asks from herself, her attorney—and even, at one point, the judge presiding over her case—to be placed with female inmates. 

According to Hendrickson, in documents provided by Carter’s mother from DOC, Carter was often referred to using the wrong pronouns by mental health providers within DOC. 

“I just think it’s pretty unacceptable to have a criminal justice system that can’t accommodate transgender individuals,” says Hendrickson.

Schroeder Stribling, CEO of N Street Village, which operates several shelters and day centers Carter used during her life, and Pathways to Housing Executive Director Christy Respress tell City Paper there needs to be more of a housing-first approach to health care, where people experiencing homelessness first receive a place to sleep, without barriers like requiring sobriety. 

“The solution to homelessness is a home,” Stribling says. She says people are more likely to be able to seek help on substance use or mental illness when they are housed. A jail cell, she says, is not the right place for someone with multiple mental health needs like Carter. 

“We have relegated mental health to the criminal justice system,” she says. 

Respress wants returning citizens to have housing waiting for them, pointing out that Carter was repeatedly discharged from the hospital or jail without a place to go, and without her care team being notified of her whereabouts. The case study also notes there aren’t specific shelters in D.C. for transgender people. 

“Ideally, someone like Alice would never have to go to shelter. People who are interacting with the criminal legal system should have prioritization directly into housing,” Respress says. 

But before a person is even arrested and potentially incarcerated, advocates tell City Paper it’s time to rethink how police interact with people experiencing mental health crises. As Carome points out, Carter’s most consistent intervention was from DOC. He says there are lessons to take from the movement to defund the police in D.C., which means reimagining public safety so mental health professionals can respond to crises. 

“There needs to be consideration of properly funding alternatives to the police in responding to people who are in mental health crisis,” Carome says. What if people could call another number than 911 when they see a person in need, he asks, and reach a behavioral health professional?

Patterson says the Department of Behavioral Health has been embracing the pre-arrest diversion program, which it launched in 2018 as a way to provide treatment opportunities to adults with substance use disorders and mental illnesses rather than arrest them. But, she notes, the key to its success is having more MPD officers properly trained in the program—and only 1 percent currently are, according to the report. 

“The whole ‘defund the police’ movement is helping us think a little more comprehensively about what tasks we have given officers carrying guns that could be undertaken by a different set of individuals with a different kind of training,” she says. She says the police reform commission assembled earlier this summer by the D.C. Council is looking into the issue. 

That hints at a broader issue outlined by Street Sense Media’s report: the need for better interagency communication and support for individuals receiving city services, as well as a broader conversation on what voluntary and involuntary commitment for treatment looks like. That should include folding clients into conversations about their own care, Respress says. 

“The Alices of the world, the people who have experienced involuntary hospitalization, they need to be at the table, talking through what it needs to look like,” she says. “And that’s just not always the case.” Pointing to the later CCE report, Ramsepaul and Patterson suggest that there be an interagency information sharing agreement, with protocols established for addressing privacy concerns. 

Both DOC and DBH declined to comment on the case study, citing their inability to comment on residents’ cases. (The agencies issued a joint statement to City Paper touting their contract with Unity Healthcare, which provides medical and behavioral health care to their clients, claiming it has helped support a push towards continuity of care.)

Patterson says the D.C. Council also has a role to play in holding agencies accountable in these situations. 

A staffer with the D.C. Council’s health committee told City Paper that an upcoming public oversight hearing on DBH scheduled for Oct. 22 will look at a number of oversight issues associated with the agency, with the case study and report likely to be discussed. 

“I think the case study really kind of points out … a lot of people who fall through the cracks of the system and then don’t get the attention they need,” the staffer said.