Caring for Homeless Mentally Ill : Innovative Program Has Cities Competing for Funds

In an unprecedented joint venture linking a large private foundation and the federal government, the nation’s 60 largest urban areas are being asked to compete for more than $100 million in new funds to help resolve one of the most intractable dilemmas facing American metropolises--the plight of the homeless mentally ill.

Its sponsors say the program, announced Wednesday, will attempt to establish coordinated treatment centers where mentally ill homeless people can receive long-term therapy and drugs they may need to control their symptoms, as well as decent housing, welfare assistance if needed and assurances their personal safety will be preserved.

Program organizers say the $103 million that will be spent is intended to beget basic changes in the way services are provided to the homeless mentally ill nationwide, a population that may number in the hundreds of thousands and possibly in the millions. The program is designed to spawn prototype local organizations that would enjoy total political and jurisdictional freedom to strip away bureaucratic delay and set policy to be observed by other agencies from police departments to welfare bureaus.

Grant, Subsidies

The program has been provided $28 million from the Robert Wood Johnson Foundation, which enjoys a national reputation for inducing major changes in the health-care system, and a $75-million in rent subsidies from the U.S. Department of Housing and Urban Development to provide housing for mentally ill street people.

Winning cities will get cash grants and loan commitments to establish local agencies to deal with the homeless mentally ill and finance innovative housing programs for them. That money will come from the foundation, while the government will provide Social Security assistance and $75 million from HUD to help guarantee stable housing for patients for as long as 15 years.

The project is co-sponsored by the foundation and HUD, as well as the National Governors’ Assn., the U.S. Conference of Mayors and the National Assn. of Counties. The advisory committee includes a range of experts, from the director of the National Institute on Mental Health to Dr. H. Richard Lamb, director of community psychiatric services at County-USC Medical Center.

The eight winning urban areas will receive direct cash grants of up to $2.5 million each and, at the same time, the U.S. Social Security Administration will provide local caseworkers to speed procedures to permit homeless mentally ill people to qualify for federal disability benefits. The Robert Wood Johnson Foundation will also provide low-interest loans of up to $1 million to each winning agency to buy or renovate housing for the mentally ill.

Unveiled at Press Conference

The new program was unveiled at a Washington press conference. In interviews, however, members of the advisory committee that organized it agreed that local politics and turf warfare in the largest of the 60 big cities may make it almost impossible for municipalities with the most extensive need to qualify for the new funds.

The doubts were voiced for cities like Los Angeles, Chicago and New York, which will compete with other cities of 250,000 population or more for a maximum of eight grants. Because comparatively smaller metropolises operate on a smaller scale, program planners believe political difficulties there are more manageable and amenable to compromise and solution than those of larger locales.

Applications must be filed by mid-May of next year with the winners to be announced in November. Sources on the advisory committee, speaking on the condition they not be identified, said they feared that politics--typified by the conflicting ambitions of Mayor Tom Bradley and Gov. George Deukmejian--may doom hope that the nation’s largest cities can participate.

In New York and Chicago, similar conflicts exist between state and city or county governmental entities.

At least one local organization, the Skid Row Development Corp., predicted, however, that political problems can be resolved in Los Angeles and that a local group will be able to start work on such a program here.

Some members of the advisory committee held out hope that one of New York’s five boroughs could emerge as a winner. In California, Los Angeles and San Francisco are thought to be long-odds choices, with San Diego seen as a promising contender. Other eligible cities here include Long Beach, San Jose, Fresno, Sacramento and Oakland.

But even if the largest cities don’t qualify for the demonstration grant money, said program director Dr. Miles F. Shore, “the hope is we will have eight imaginative new ways of organizing things that can be demonstrated in sufficiently large cities so people can take a look and adapt them (elsewhere).”

The concept announced in Washington is similar to a “new partnership” between the public and private sectors proposed in the final report of a national commission on mental health during the administration of former President Jimmy Carter but never acted on by the federal mental health bureaucracy. The Carter commission delivered its final report in 1978.

Dr. Thomas E. Bryant, who was chairman of the Carter-era commission and now heads the Washington-based Public Committee on Mental Health, said he hoped the big-buck initiative announced Wednesday can succeed in an area where virtually all other attempts at progress have failed. Bryant is not involved in the new program.

“I was convinced when I finished with the commission that the major underlying problem remains the stigma associated with mental illness,” Bryant said.

Not Sympathetic

“People are not (oriented) toward sympathy (with the homeless mentally ill) and that problem is made much worse by the sort of misunderstanding (of mental illness) that has been perpetuated for centuries. There is a lot that can be done, but it’s the kind of problem that, since the public does not understand it, elected officials don’t feel any kind of pressure (to do anything about it).

“It is very easy for this type of thing to get swept under the rug, especially since those people are down there in inner-city areas.”

In urban areas, the homeless mentally ill pose special problems for health-care workers who try to identify and treat them. The homeless represent an unwelcome result of a now 30-year-old change in public policy that saw the demise of large state mental hospitals and the resulting “deinstitutionalization” of tens of thousands of mentally ill people.

Such a policy came into vogue because the large state mental hospitals were perceived almost universally as brutal, inhuman prisons for the mentally ill that had been so corrupted over time that nothing short of fundamental reform--in which such places were essentially eliminated--would be acceptable. Unfortunately, the reform turned out to be more onerous in many ways than the condition it was intended to correct.

What really happened was that, though public mental hospitals largely emptied and court decisions strengthened people’s abilities to resist being committed, community and outpatient treatment programs that were to have been established to replace the hospitals either did not develop or came into being on too small a scale to be effective. Budget cuts and financial restrictions have generally imposed such extensive limitations on community mental health services that most homeless mentally ill--who tend to be accorded the lowest priority of all--have remained essentially unserved, according to Shore and other professionals interviewed by The Times.

So overwhelming has the problem become, said Dr. John A. Talbott, chairman of the psychiatry department at the University of Maryland School of Medicine and a member of the advisory committee, that “we don’t even know the numbers” of people involved. Talbott said there have been estimates of the total number of homeless people in the United States ranging from as few as 250,000 to as many as 3 million and projections that as few as 20% to as many as 90% of them may suffer from some form of mental illness.

In California, Dr. D. Michael O’Connor, state mental health director, conceded there are no reliable estimates of the number of homeless mentally ill in the state and declined even to guess at the extent of the problem. O’Connor said the state welcomes the new foundation-government program and he noted California is currently reviewing county applications for distribution of $20 million in new state aid for homeless mentally ill people.

Hospitalized Mentally Ill

The official announcement of the new Robert Wood Johnson Foundation national program noted that the number of hospitalized mentally ill people dropped from 560,000 in 1955 to 120,000 in 1980, while the number of seriously mentally disabled is believed to have increased from 1.5 million 30 years ago to 2.4 million now.

“Emerging from (attempts to deal with the problem in the last 30 years) is a consensus that, while the rationale for deinstitutionalization is a sound one, its implementation has been flawed,” the announcement said.

“The most visible evidence of the (failure) . . . is the now familiar sight of disturbed men and women living on the streets of every major city in the country.”

Preference for the loans will be given to cities that can figure out ways to use the proceeds to procure still more money to acquire or construct housing, said Shore, the Harvard University psychiatrist who will serve as director of the program. An imaginative--if theoretical--possibility outlined by Shore would be for a state mental health agency to use funds to develop income-producing facilities on unused land that once was a part of a state hospital system. The profit generated from such investment would then be used to pay for urban outpatient care for the homeless.

HUD will provide $75 million worth of rent subsidy certificates, permitting mentally ill people who receive them to continue to get housing assistance for as long as 15 years.

An immediate problem, the project’s sponsors say, is a basic one: Not all homeless people are mentally ill and even those who are often do not wish to be identified as disturbed and are prepared to go to great lengths to avoid being forced into treatment.

In 1984, Shore, who also heads the Massachusetts Mental Health Center in Boston, proposed in a medical journal article written in concert with Dr. Jon E. Gudeman, a Boston colleague, that new, regional inpatient centers be established to provide comprehensive services to those few patients whose condition requires commitment. The centers would be small--150 to 200 beds each, with services provided in smaller sub-units of 25 to 30 patients. Staffing would be intensive and costly for the patients housed there, but the intention would be to remove from the street those people who cannot function on their own.

“I agree that it (deinstitutionalization) has been a disaster,” Talbott said in a telephone interview. “Our problem to date has been that we are able to provide very good psychiatric services for some people, mediocre services for others and no care for thousands of people.”

A Fraction of the Need

In fact, conceded USC’s Lamb, the new $103-million project represents little more than a fraction of the amount of money that would be needed to provide services for however many homeless mentally ill people there may actually be in the nation’s cities. But he said the program has a “hidden agenda” in that it seeks to let a handful of cities try to establish ideal programs whose existence could force the hands of other municipalities once successful programs--and ways to pay for them--were demonstrated.

“We recognized that the chronically mentally ill tend to congregate in the cities, which are the least prepared and motivated (entities) to try to do something about this problem. One of the things we want to do is have cities serve as models, but we also wanted cities to get their act together organizationally.”

Working against successful programs for the homeless mentally ill, agreed Lamb, Shore and other experts, are traditional bureaucratic barriers separating city, county, state and federal governments. Lamb noted that, historically, mental health care has been a function of state government--dating to the era of the large state mental hospital.

But for homeless mentally ill people at the local level, a state bureaucracy may be too remote. What the new program envisions, said Lamb and Shore, are agencies of a different type--perhaps public, perhaps nonprofit private--unlike any that exist now. “The agency (that would be created) would have the backing of people high in all levels of government,” Lamb said. “In order to cut through political and turf issues, I think it would need to be given the power to do what needs to be done.

“It would need to have the power to tell the county welfare department, ‘You will do this and you will stop doing that,’ and the same thing with all other parts of government. It would need to have that kind of clout. It would have to be run by people who are good administrators who know what they are doing and who are not perceived as (for instance) threatening the mayor.

“Are we asking a lot? Yes, we are. But on the other hand, the problems of the chronically mentally ill in the cities are going to have to be solved. And if they are going to be solved, these things are going to have to be done. While this is asking a lot, it is asking what’s necessary. It’s time we did that.”

Dr. Robert Glover, director of the Colorado Division of Mental Health and another advisory committee member, said that what must be created are local agencies that can--easily and without significant amounts of red tape--link the services of private and public agencies and coordinate services of government departments providing unemployment, housing and health benefits.

Mental Health Budget

A major part of the power necessary to succeed, Glover said, would be the power to make a separate mental health budget that would include money from all different levels of government, with the coordinating agency given the power to spend the money as necessary.

“Let me put it this way,” said Shore. “The situation (treatment for homeless mentally ill) as it stands is not so hot, so if we don’t try to do something different, then all we’re going to do is have the same old things go on and the situation will continue to be not so hot.

“A lot of us feel that, while more money is needed, a major part of the problem in urban areas is the system. The money, the administrative responsibility and clinical responsibility (for actual treatment programs) are often so divided up in different parts of government or government and the private sector that the system doesn’t work nearly as well as it could.”