Closely Watched Experiment : Involuntary Commitment Aids Many N.Y. Homeless

He was a balding middle-aged man with a long beard, and he lived in a giant flower box on a busy Manhattan street.

When he was picked up, dirty and disheveled in the dead of winter and taken to Bellevue Hospital, staff members at the special psychiatric unit for the homeless were pessimistic. He paced the hallways, complaining about his family, medications and the police. He cursed so badly that physicians barred him from group meetings. After other patients had finished meals, sometimes he foraged in their leftovers.

For more than a month as he strode the halls, an occupational therapist periodically walked with him, providing one-on-one contact and quietly acknowledging his complaints.

Then one day, the man walked into the dayroom where other patients were drinking coffee. He said two words: “I’m ready.”

From that moment on, he wanted to go to every group session. In music therapy, he composed “very playful” songs and was equally playful in dance therapy, one of his therapists said. Gradually, he began to be comfortable with social contact. No longer was he a hermit.

Today, he is living productively in a community residence.

It has been almost a year since New York City--in an experiment closely watched by municipal officials and psychiatrists across the nation--began removing the homeless with serious mental illnesses from the streets and involuntarily hospitalizing them. After a year, psychiatrists have found that even some of the cases that seemed most hopeless can be helped significantly. But the task often is difficult.

Physicians and social workers can tell heart-warming stories of progress--families reunited, patients beginning to lead productive lives. They say that significant numbers of chronic patients, thought to be virtually untreatable, have shown marked improvement when sufficient time, staff and support services are available.

Unremitting Pressure

But medical personnel also bemoan the pressures of trying to treat an unending tide of mentally ill homeless under tight budget constraints and with hospital administrators pushing for quick discharges. At Bellevue, doctors and nurses facing staff shortages toil with the unremitting pressure of knowing that many more mentally ill homeless with crushing problems are still on the streets or in Bellevue’s psychiatric emergency room, which is always full.

“We do medical and psychiatric assessments and social service assessments and move them on,” said Dr. David Nardacci, the homeless unit’s director at Bellevue. “It’s like a seven-week triage unit.”

After treatment at Bellevue, the initial plan called for placing within three weeks a third of the homeless in community residences, another third in supervised shelters and sending the rest to a special 60-bed unit set up at Creedmoor Psychiatric Center in Queens. But social workers soon found that placements took from six to eight weeks.

“These patients are often so isolated for so long, it takes them a long time before they can accept the idea of going into placement and speak for themselves well enough for them to be accepted in an adult home or community residence,” said Harriet Ruschmeyer, the unit’s social work supervisor.

Reaffirms Suspicions

“I think some of the suspicions we had at the beginning, that the (homeless) population was sicker than we thought have been reaffirmed,” Dr. Nardacci declared. “They do need a longer time in the hospital. More of them do need state hospitalization.”

More than 200 of the homeless have gone through the program at Bellevue’s 18 West Adult Psychiatric Unit--a locked ward with sweeping views of Manhattan’s skyline. Of these, 110 have been transferred to Creedmoor, a New York state psychiatric hospital with an equally spectacular view of Little Neck Bay. The rest have been reunited with families, placed in group homes or supervised shelters. A small number have been released on their own. Three or four patients a week are sent to the state hospital, which has successfully resisted pressures to admit 8 to 10 weekly.

Creedmoor officials said that they have discharged 30 of the patients successfully. A dozen are living in adult homes in Queens, 8 have been reunited with families or friends, 3 are living in single apartments and 7 are temporarily residing as outpatients in a crisis residence on the state hospital’s grounds. Seven patients are waiting on the ward for beds in nursing homes. These statistics please hospital administrators.

“It’s probably one of the only success stories with this population in this type of setting,” said Alan M. Weinstock, Creedmoor’s chief executive officer.

21 Patients Flee

But problems persist. Fifteen patients required such long-term care that they were transferred to other wards at the state hospital. Twenty-one homeless patients have fled Creedmoor since last December, most while visiting community residences for a day to decide whether they want to live in them.

Such runaways can be frustrating to staff members who have worked with the patients and have brought them to the point of discharge.

“For a worker who spent months, it is hard,” Weinstock said. “The good news is that a number of the ones who have escaped have contacted us, and we have hooked them up to places in the community. We tell them they can come back any time they want, and if they want to use a case manager, they can. Some have.”

When most patients are transferred from Bellevue, they immediately announce to nurses and physicians at Creedmoor that they are going to run away. The lure of freedom on the streets is powerful. Staff members have learned to use the urge to wander as a treatment tool.

Creedmoor’s 60-bed unit for the homeless on two floors of a beige brick building is specially designed so that patients used to years on the streets will not feel cramped. Unlike other wards that occupy half a floor, the homeless unit spans entire floors.

Room to Walk Around

Patients, who have been loners for years, have plenty of room to walk around. Physicians also have learned that recovery is hastened when few demands are placed on the homeless. Unlike other wards at Creedmoor, little pressure exists to take part in activities. Staff members deliberately take their time in enticing homeless patients to be part of therapeutic groups.

“We’re not pressuring,” Weinstock said. “The lack of pressure on them is the key factor. . . . They have been through all types of rehabilitation and training programs. They don’t seem to do well with the pressure. When we learned that, we put the low demand concept into effect.

“One of the things we’ve learned about the whole concept of homelessness, it’s not the Wall Street banker who went broke. Most of them did not have high-level jobs and were probably marginal people in society. There wasn’t one precipitating event that got them into the streets. It was a slow process, and the last step was a parent died or they lost an apartment. It was over a period of time, the downward trend.

“These are people who generally had very few skills, generally did not do well in school, generally did not finish school. It shows the need to retrain them, develop all sorts of training programs.”

Have Smaller Caseload

Case managers who follow the homeless once they are released from Creedmoor, work in the ward to befriend their patients. Unlike other social workers who may have as many as 50 cases to follow, these managers have a caseload of 10 patients. Once a patient is discharged, the manager is responsible for seeing that appointments, such as those with welfare workers, are kept or insuring that the person has a place to live.

Under a new program, managers will have $4,000 available for each patient for emergencies. Thus, if someone is evicted, the case manager will be able to rent a hotel room on a temporary basis. Creedmoor also has installed a 24-hour-a-day hotline for former patients. The hospital switchboard operator can reach the case manager on nights and weekends. If the manager is not available, someone else will respond. The hope is that such aggressive follow-ups will cut the readmission rate.

Creedmoor’s psychiatrists were surprised at first when they surveyed the homeless. They had anticipated an older population, but many patients were in their 20s and 30s. Many were from out of state.

Significant numbers suffer alcohol and narcotics addiction and serious physical illnesses. Administrators have opened a special ward at the state hospital just to treat the chemically abusing mentally-ill.

Bring Many Complications

Some patients arrived with all the complications of street life: frostbite so serious that skin grafts were required, tuberculosis, liver, stomach, skin, blood pressure and nutritional problems.

When the first group of the homeless was picked up from the streets and taken to Bellevue last October 29, legal aid lawyers pressed the courts to reverse involuntary commitments. Much of that pressure has stopped and physicians now generally go to court asking for legal permission to administer medications or to transfer patients to Creedmoor, if they resist.

In the intensive, emotionally draining atmosphere at Bellevue, staff members who sometimes function as substitute families, must guard against burnout. Budget cuts at Bellevue increase that risk.

“If the nurses are unhappy, if they are burned out, if they feel stressed, that gets translated to the patients unavoidably,” Dr. Nardacci said. “And the whole nature of the ward environment, instead of being a warm nurturing environment, can become a punitive holding area.”

So far burnout hasn’t happened and social workers have even acted as detectives, going through old telephone directories, visiting former addresses and examining mail boxes in abandoned buildings for clues to reunite families.

Staff Gets Surprised

The staff has experienced some pleasant surprises. Many of the homeless have turned out to be very creative, a seemingly higher proportion than other psychiatric patients at Bellevue. Activities therapists have responded with creative techniques of their own. Sometimes an art therapist will draw portraits of homeless patients.

“It’s a way of acknowledging who they are and appreciating who they are,” said Jo Anne Frohock, head of activity therapies. Frohock’s staff also neatly frames and displays the patients’ art work. “The message,” she said, “is ‘I think what you do is really good, I think you’re really good,’ so maybe that kind of feeling will transfer to them in helping them with their self-esteem.”

Clearly, the homeless units at Bellevue and Creedmoor are innovative models. But even the most optimistic staff members say it is only a beginning.

Wants Political Decision

“We can start with a unit like this, and we can affect the lives of the individual patients who come through here,” Dr. Nardacci said. “But the ultimate decisions have to be political.

“What kind of priority is homelessness? How much public funding do we want to allocate for community residences, for state hospital beds, for research into medications? Because unless we as a country see this as a priority and enact legislation to provide funding or perhaps think of changes in our concept of commitment and hospitalization, the problem will persist.”