Critics Call Effort a ‘Smokescreen’ : N.Y. Tries to Build Bridge to Homeless Mentally Ill
As he muttered incoherently on a busy downtown sidewalk, Frankie was not a threat to anyone, except perhaps himself. The gaunt, disheveled man was homeless, turning purple on a bone-chilling afternoon and lost in a bizarre world all his own.
“I just got back from Warsaw,” he mumbled to the passing crowd, his eyes darting up and down the street. “I got gold mines in South Africa. By now, the priests and rabbis in this neighborhood know me pretty well.”
One day last month, as a freezing wind began to blow, New York City psychiatrist Neal Cohen gently persuaded Frankie to visit Bellevue Hospital. There, Cohen told him, he could have a checkup and “feel better.” Frankie heaved a sigh, tossed a paper cup reading “I love New York” to the sidewalk and climbed into Cohen’s van.
It was all part of a controversial New York program to round up a small group of mentally ill homeless people and bring them to a mental hospital for treatment, if necessary against their will. Local officials have called it a first step toward helping street people, but critics say it is a drop in the bucket, given New York’s nearly 50,000 homeless.
Regardless of the debate, New York is one of the few cities trying to do something about the estimated 250,000 mentally ill people who have become fixtures on the street corners of the nation’s big cities. Although the majority of street people are not mentally ill, federal surveys estimate that more than 20% show signs of such illness.
A recent survey of the Los Angeles Skid Row population, for example, disclosed that 28% to 33% of those surveyed were mentally disabled. In other areas, the estimates run as high as 50%.
As cities such as New York and Los Angeles grapple with the problem, the federal government has been slow to respond. Congress, which funded some innovative programs to treat the homeless mentally ill earlier this year, has now cut back on such efforts. Given the nation’s fiscal difficulties, there is no indication that such funding will be expanded anytime soon.
“Washington has failed terribly in providing funds for hospital care, as well as community facilities for the homeless mentally ill,” said Jill Halverson, who directs the Downtown Women’s Center in Los Angeles, which helps mentally disabled street people.
“And the sad thing is these are the people most in need, the people on our streets who clearly can’t take care of themselves,” she said. “There is so little really being done for them.”
In the absence of a national strategy, several cities have devised short-term programs to help the homeless mentally ill, including drop-in clinics on the street and mobile outreach programs. But, in New York, Mayor Edward I. Koch decided to try something different.
Last summer, during a meeting of the American Psychiatric Assn., he announced plans to round up about 500 of the city’s most seriously disabled homeless people and rotate them through a newly created 28-bed psychiatric unit at Bellevue Hospital.
Debate Goes On
Similar ideas about extended hospitalization are being debated in Los Angeles and other communities. But New York is the only city that has actually taken such action.
“Enough is enough,” said Koch, who initiated the program after visiting the streets to see some of the city’s most severely disabled people. “We are going to take care of these people. Someone has got to show some leadership on this issue.”
Koch brushed aside objections by American Civil Liberties Union attorneys and expanded the city’s interpretation of a state law setting conditions under which people may be kept involuntarily in a hospital.
Previously, mentally disabled street people could not be kept in medical custody for more than a few days unless they posed an imminent danger to themselves or others. Under the new plan, New York is also committing people who are a danger to themselves in the foreseeable future.
As a result, New York now has “legal latitude” to bring in selected persons and treat them in the special ward at Bellevue for at least three weeks, Koch said. Patients may later be sent to state hospitals, halfway houses or city shelters, or they may simply be discharged back to the streets, depending on the assessments of their physicians.
Those confined are entitled to a court hearing within five days, if they request it.
Some Extreme Cases
In recent weeks, the city has rounded up some extreme cases: a woman who slept on the street, defecated in her clothes and tore up dollar bills given to her by pedestrians . . . a lice-ridden man who lived on a rock in Central Park inside a plastic bag filled with rats . . . a nearly blind woman who lived on a sidewalk and screamed at passers-by.
Not surprisingly, Koch’s plan has drawn fire from critics in New York and across the nation. Many of them believe that simply rounding up street people and putting them in overcrowded mental hospitals is unconstitutional and does not address the real problem: the lack of low-cost housing for the homeless.
“This program is a smoke-screen,” said Robert Hayes, president of the New York-based National Coalition for the Homeless. “It diverts attention from the issue and makes people think that the real problem is in the skull of those people crazy enough to be living out on the streets.”
The bottom line is that New York has thousands of homeless people who need mental help and housing, Hayes added, and “a 28-bed unit at Bellevue is only a drop in the bucket.” On any given night, he said, there are “untold numbers of people who need help in psychiatric hospitals or decent housing, and they’re turned away . . . . They aren’t getting it.”
Moreover, critics note that it costs about $50,000 a year to care for a patient in a mental hospital and contend that it is unlikely that New York, California or any other state can seriously contemplate putting large numbers of street people into such institutions.
Sees Shortage of Beds
Dr. Luis Marcos, who heads New York City’s mental health services program, conceded that the city suffers from a shortage of hospital beds and that the mayor’s homeless program targets only “a small percentage” of those in need.
“But this program is a beginning, an effort to work with the state, to focus attention on the problem,” he added. “There are people out there who need help, and we’re trying to provide that help as quickly as we can. Our critics seem to forget that.”
There is little debate, however, on the origins of the problem. Most politicians, homeless advocates and mental health experts say there are several reasons for the growing number of mentally ill homeless people wandering the streets of American cities:
First, a controversial national policy begun in the early 1960s caused hundreds of thousands of patients in state mental hospitals to be discharged and returned to their communities, usually without supportive social services or psychiatric programs.
The so-called “de-institutionalization” movement featured an unlikely alliance between civil libertarians, who were eager to rescue patients from the abuses of mental asylums, and conservatives, who wanted to cut services and save millions of dollars. Mental health workers also supported the program, confident that powerful new drugs like Thorazine and Haldol would “stabilize” patients and enable them to live productive lives in the community.
Halfway Houses
A key part of the plan, recommended in legislation signed by President John F. Kennedy in 1963, was the construction of a nationwide network of community halfway houses and mental health centers for these former patients. But few such facilities were built, even though they were far less expensive to operate than hospitals.
American taxpayers “were not exactly waiting at the gates of the nuthouse with open arms . . . . It was all pretty naive to think this would actually happen,” said Father John Felice, a Franciscan priest who runs a home for mentally ill street people in New York.
As a result, many former mental patients drifted into the downtown areas of American cities, where they found cheap lodgings in rundown apartment buildings and flophouses, along with junkies, prostitutes and other vagrants. Few of them had access to steady psychiatric care, but many received minimal government benefits and at least had a place to stay.
These inner-city havens, however, were sharply reduced in the 1970s by sweeping redevelopment programs in Los Angeles, New York, Chicago and other cities. Many of the hotels in which former mental patients had been living fell to the wrecker’s ball and were replaced with high-rise buildings, convention centers, boutiques and restaurants.
More than 500,000 such units were destroyed nationwide, and a multitude of people were literally forced into the streets. A substantial number were mentally disabled.
‘Safety Net’ Disappears
The final blow occurred in the 1980s, when the federal government cut back heavily on aid for low-cost housing, community mental health programs and Supplemental Security Income payments for disabled people. Suddenly, the “safety net” for thousands of destitute Americans “had virtually disappeared,” Hayes said.
As the legions of homeless people grew, so did the numbers of those who were mentally ill. Thousands of younger people who had mental problems and were destitute joined the ranks of those who had been discharged from state hospitals. Many had no contact with family members, who had either cut off ties or lost contact with them long ago.
Frankie’s story is a case in point.
Although their information is sketchy, Cohen and other psychiatrists have a rough idea about the man’s background. In discussing his case, they asked that his real name not be used.
In recent years, Frankie had been hospitalized in a state mental institution and later released into the community. On occasion, he was briefly committed to a city hospital. No family members could be contacted to find out more about his condition.
The city’s community outreach program, known as Project HELP, had tracked Frankie on the street for months, offering him clothing and food. Social workers said his physical condition had deteriorated recently, noting that he had been losing weight and rejecting food.
Avoided Shelters
During the last few years, they added, Frankie was referred by the city to lodgings in a hotel but frequently wandered away and disappeared. Occasionally, he would panhandle enough to rent a $30-a-night room for several nights at a time. He did this to avoid staying in shelters, where, he told social workers, he had been beaten up several times.
At Bellevue, Cohen noted, Frankie would be offered medication to bring him out of his shell and help him reconnect with reality. He would also receive intensive therapy. If that failed, psychiatrists might then recommend long-term treatment in a state mental hospital.
Frankie was lucky, compared to the large number of homeless mentally ill people who receive little attention. Dr. John Talbott, past president of the American Psychiatric Assn., said there is a “vast, unmet need for this population.”
“Some of these people need to be in hospitals,” he added. “Others should be in community homes. Either way, that help isn’t there, especially from the federal government.”
Earlier this year, Congress approved legislation to provide more than $350 million in aid to the homeless. And, looking to the future, lawmakers authorized $100 million for “transitional housing” projects in selected cities that would provide a stable community residence for homeless mentally ill people.
Now, the budget crisis on Capitol Hill has caused Congress to slash that funding to $65 million, an amount “that comes nowhere near meeting the national need,” according to Maria Foscarinas, counsel for the National Coalition of the Homeless. Other programs that target the homeless mentally ill, such as demonstration projects in several cities to explore innovative community-based solutions, also are threatened.
Even if such funds were available, mental health experts say, the unusual problems confronting the homeless mentally ill would continue to make their work very difficult.
“The first thing you have to overcome is the fact that these people don’t trust you--don’t trust anyone, for that matter--after what they’ve been through,” said Amelia Klein, a social worker who helps the homeless mentally ill in Philadelphia.
Building bridges to them can take time, said Dr. Katherine Falk, a New York psychiatrist who runs a volunteer counseling program for the homeless mentally ill.
“These people aren’t your typical psychiatric clients because they don’t have anywhere to go,” she noted. “You can’t impose your clock on them. If it takes six months for them to trust you enough to come into an office and take a shower, then that’s what it takes.”
More important, professionals who work with this population caution that the bizarre ravings and grandiose delusions of some street people may be vaguely related to reality, even though they indicate a severe state of mental illness.
Cite Defense Mechanisms
In a 1985 study of homeless street women, one researcher for the National Institute of Mental Health looked at the world from the vantage point of street people and concluded: “When young kids taunt you and urinate in your hair . . . it helps to believe you are actually the mayor of a large city or that you have friends in powerful places who would love nothing more than to exact revenge on those who victimize you.”
As he rode in the van toward Bellevue Hospital, Frankie mumbled sporadically about gold mines in South Africa, talked about “powerful friends” in Connecticut and complained that people had been stealing his paychecks. But most of the time he was silent.
“We’re going to take very good care of you,” said a nurse riding in the van, reassuringly patting his knee. “You can trust us.”
Frankie stared at her blankly. “Whatever you say,” he replied. “I’m just fine.”
Postscript: In the weeks since he was brought to Bellevue, hospital officials determined that Frankie required continued psychiatric care. There is no indication of when he will be released from the hospital or sent to another facility.
