N.Y. Hospital Is Policy Laboratory : Homeless Psychiatric Unit Measures Gains in Inches

Behind a locked, bright yellow door on the 18th floor of Bellevue Hospital, a colorful impressionist landscape celebrates Christmas.

Trees and a house are drawn in vivid greens, blues and reds, with a greeting, “Ho, Ho, Ho,” painted in shaky brown letters almost running off the paper. On another wall is a snowman with coal black buttons. It was done by the same artist, who reached back into her own life to name her creation.

“Homeless Snowman,” the patient wrote.

It has been almost two months since New York City began removing from the streets and involuntarily hospitalizing homeless persons who are seriously mentally ill. Since Oct. 29, physicians and police officers have taken 22 men and 19 women--a few in handcuffs--to Bellevue’s 18 West Adult Psychiatric Unit, with its spectacular views of Manhattan’s skyline.

On 18 West, progress often is measured in inches.

Mayor Edward I. Koch, bearing treats, visited the ward on Thanksgiving. The first person he approached was a particularly vulnerable looking man in his late 20s, who held both hands up defensively when the mayor came close.

“Would you take a cookie? Do you want a cookie?” Koch asked.

“I don’t think I should,” the man stammered.

The unit’s executive director quietly explained that the patient was paranoid and probably thought the mayor was trying to poison him.

“Of course not, you shouldn’t take the cookie now,” Koch countered. “Just think about it. I’ll be back.”

During his tour of the unit, the mayor saw other patients playing checkers or watching television. He stopped to chat, and all accepted his offer of food. Finally, on his way out, he passed the first patient again.

“Last chance,” coaxed Koch. “Do you want the cookie?”

“I’ll take it,” the man replied, at last accepting and eating the food.

Although most progress is made in such painstaking small steps, for some patients there has been genuine improvement.

Four of the first 41 patients have been discharged, some in the care of long-lost relatives. Several have been shifted to other wards after physicians found medical rather than mental problems. Eight others have been transferred to a special 50-bed homeless unit set up by New York state at Creedmore Psychiatric Center for longer term care.

Everyone Learns Patience

“One thing everyone learns is patience,” said Dr. David Nardacci, the homeless unit’s director. “We’re dealing with people where changes are measured more slowly . . . . You have to be sort of content with what, to someone else, might seem to be a more minor victory--but nonetheless, a real victory.

“One patient who couldn’t sit in a dining hall with other patients can now sit in the same room and eat lunch. Aside from just asking other patients for a cigarette, the patient can now ask someone else a personal question: ‘Oh, why are you here?’ ”

Since Oct. 29, 18 West has become both a medical model and a public policy laboratory, watched closely by psychiatrists and municipal officials across the nation.

By deciding to move actively to pick up and hospitalize the homeless who are unable to care for themselves or who risk harming themselves or others in the foreseeable future, New York City has moved against the decades-long tide of freer discharge of mental patients from institutions. New York’s program stresses the need for asylums and other forms of supervised shelter for the most serious cases.

Despite strong initial opposition from civil rights groups, Koch and psychiatrists at the New York City Health and Hospital Corp. believe the new approach is working.

‘May Not Be Enough’

“This may be the beginning of some realization on the part of policy makers and the public that we need to do something, that we really need to look at the system in a really drastic way,” said Dr. Luis R. Marcos, the Health and Hospital Corp.’s vice president of mental hygiene services. “ . . . It may not be enough. A year from now we will probably know it is not enough, but it is a good beginning.”

Koch challenged his opponents during an interview with The Times. “I say the people who interpret the Constitution to prevent us from helping those who are totally incompetent, who can’t help themselves, they are dumb,” the mayor said. “I went to (Chicago Mayor) Harold Washington’s funeral and the mayors came over and said it’s terrific what you’re doing, Ed.”

Nevertheless, the patients now in Bellevue’s special homeless psychiatric unit make just a ripple in a great tide. Municipal officials now calculate New York City’s total homeless population at about 40,000. At night, about 10,000 of the homeless use shelters.

Others are housed in welfare hotels or make other arrangements. Health and Hospital Corp. workers estimate that about 2,000 people live on the streets, refusing to sleep in shelters. Some studies estimate that between 40% and 60% of the homeless suffer from mental illness. Among the permanent street people, the incidence of mental illness--particularly chronic schizophrenia--is believed to be higher yet.

Bellevue’s psychiatric emergency room, and the emergency rooms of other municipal hospitals, are always crowded. Seriously ill patients being treated and fed sometimes are handcuffed to gurneys for days awaiting beds or waiting for the effects of crack and other drugs to wear off.

Long Waits for Beds

On a recent day, 20 people waited in Bellevue’s emergency room to be admitted to psychiatric beds. Municipal hospital psychiatric wards that day were running at 102% of capacity. The problem is not just the homeless. In 1976, New York City police transported 1,084 extremely disturbed people to municipal hospitals for psychiatric evaluation, but by 1985 the number had risen to 17,237.

At the same time, because of deinstitutionalization, the number of state psychiatric hospital beds available for New York City patients has dropped dramatically, from about 12,000 in 1965 to about 4,100 today. The incidence of mental illness, however, has not decreased.

When municipal hospital emergency rooms become too overcrowded, an arrangement city and state officials have labeled the “tripwire” is activated. Municipal hospital administrators bargain with state hospital personnel over how many of the day’s patients can receive acute short-term care in some state hospital. It is not unusual for a patient to travel by ambulance to an upstate hospital far from the city.

City officials stress that no patients who are homicidal or suicidal are turned away--even if they have to be kept in an emergency room for days until a bed is found. But others badly in need of treatment are rejected or referred to private hospitals--if they have insurance--or to municipal clinics.

In Bellevue’s 18 West Adult Psychiatric Unit, both patients and staff have shared a learning experience. Some staff members were apprehensive when the first group of homeless, rounded up from the streets, arrived for treatment.

‘Let’s See What Works’

“There were all these questions, and we didn’t know what to expect,” said Jo Anne Frohock, head of activity therapies. “I think there has been a real sort of spirit of adventure: ‘Let’s try it. Let’s see what works.’ ”

Many of the homeless were extremely hostile--and had retreated to early stages of childhood--like toddlers playing near to each other, but separately, in a sandbox.

Staff members tried at first to get the homeless out of bed for a meeting.

“We met a lot of resistance and, even when we did encourage them to come out, they were isolated. They wanted to sit by themselves,” said Leroy Edwards, a nursing supervisor. “They did not want to communicate with each other. You have to give them time.”

One man was so silent for so long that staff members thought he was mute. “He was refusing everything. He was not saying anything,” Edwards recalled.

A woman patient was just the opposite. “I had a lot of patients swear at me, but this was done really professionally. After you accept that type of language and behavior without getting excited and not getting upset, you continue to try to be therapeutic.”

‘Thanks for Understanding’

Finally, there was a breakthrough. Later, the patient came back to Edwards and told him: “Thanks for understanding.”

To coax the homeless to activity therapy, staff members set up bingo games but saw that everyone got prizes. Activity therapists found that homeless men and women concentrate better with background music--particularly new wave and the opera “Tosca.” But getting the patients to work with one another on projects remains difficult.

“You have to respect their boundaries, because they wouldn’t have gotten to the place they were if they had good boundaries,” Frohock said. “They are very fragile. When they need to back off, you have to let them have that kind of space.”

“These patients in some ways are no different from other psychiatric patients,” Nardacci said. “The commonest diagnosis we treat is schizophrenia . . . . What I think differentiates these patients is that, in general, they tend to be a little more regressed, a little more withdrawn, a little less social. These are the kinds of patients who would not seek assistance on their own.”

Private hospital psychiatric wards also are crowded, and waiting lists for beds are common.

Legal Route Is Last Resort

Not only is it difficult to get many patients to socialize, but some reject medication and cannot be given it unless doctors go to court to press the issue. But the legal route remains the last resort. Persuasion is paramount.

“My own approach is to be very direct and very straightforward and to really put things in terms that a patient will understand,” Dr. Nardacci explained. “If the patient looks anxious or uncomfortable, if the patient has obvious physical problems, again I will basically reinforce the fact that you want to leave the hospital, but you are in some kind of pain. ‘You seem tormented by these voices you are hearing . . . . Now let me remind you that you don’t seem to be as happy or as comfortable as you are telling me.’

“And we begin to work on this. By them understanding that I understand some of the problems, we start to go from there. I just can’t come in and say you need medication because I say so.”

The process often takes constant reinforcement. “It really is understanding what is most bothersome, what it was out on the street. ‘It really wasn’t all that wonderful, was it?’ ” Nardacci will ask a patient. “ ‘You were out there. You were often hungry. You were often frightened.’ ”

” . . . We find a lot of denial. They will tend to minimize the psychiatric. It’s routine for them to say, ‘I don’t have a psychiatric problem. Those other people here do, but not me.’ That’s very common. We’re talking about serious mental illness. None of us, the psychotic as well as the non-psychotic, like to admit we have problems, problems of this magnitude, particularly with the stigma that’s attached.”

Some Rooted in Delusions

Some patients, despite all the effort, remain firmly rooted in their delusions. One woman still is convinced she is a federal marshal.

“We’re getting results, again not in every case, but the general trend is that the patients are improving,” Nardacci added. “The patients are developing, if not a limited insight, at least the ability to trust and to comply with our recommendations. We’re certainly accomplishing something.”

Day on the unit begins with breakfast at 7 a.m. Patients often are reluctant to shower, brush their teeth or comb their hair and have to be taught again the basic skills of living. After medication, they are encouraged to attend activities groups, including painting, crafts, dance therapy and other skills designed to stress self-esteem and socialization. After lunchtime and medication, the patients meet with physicians and resume activities. After medication and dinner, most of the evening is spent watching television.

Even following such a simple, structured routine can be difficult for people who spent long months on the streets.

“I think we are finding it is taking a lot of our patients a lot longer (than expected) to get better,” said Harriet Ruschmeyer, the unit’s social work supervisor.

‘Tender, Loving Care’

“Working here, you need a lot of patience,” said Nancy Loo, a nurse on the unit. “They need a lot of tender, loving care and teaching.”

As Christmas approaches, many of the homeless taken from the streets have become excited about the holiday. Recently, a group of carolers visited the ward. After hearing the traditional Christmas songs, one woman looked as if she were going to cry. Frohock, the head of activities therapies, quickly whispered, “Let’s do an up tune next.”

Patients have been busy making decorations for the unit’s tree. “All the patients worked and worked,” Frohock said. “I think that was kind of closest to a family kind of home experience, working on their Christmas decorations and the tree.

“It’s a jolly little tree, and I think they’re awfully proud of it.”