Housing for the homeless, and treatment too

In Australia an effort is underway to house many of the chronically homeless. Experts involved are working to stem the underlying causes of homelessness by providing not just housing, but treatment too.

"It's futile to try to treat a mental health problem if the patient doesn't have a decent place to live," he [Dr. Nicholson] said.

"Similarly, it's very hard for that patient to sustain a tenancy if they have a florid mental health problem or alcohol and drug problem, so the answer has to be a much more integrated response from our service provision."

Safety must supersede freedom

Three homeless men died on Long Island in the severe weather. Alexander Roberts, a homelessness advocate, writes in Newsday today that those deaths, “would have been avoided last week if police were allowed to force people living on the street into a temporary shelter in the freezing weather.”

He recounts the sad 20 year old story of Billie Boggs, a woman “protected” by civil libertarians from involuntary treatment, who was able to gain her freedom to live with psychosis and without a home.

Robert suggest that the answer should be involuntary shelter for people who are “imminently dangerous” to themselves and will not take care to get themselves out of the freezing cold. An even more helpful solution is for the mental health system to start caring for those who are homeless due to untreated severe mental illness; for mental health professionals to use both the inpatient and outpatient treatment laws to help restore such individuals to a level where they can make competent decisions about the need for shelter; and, for all of us to hold the mental health system responsible for maintaining the safety net for the individuals it so routinely tosses to the elements.

Real reform overdue at your public library

Urban public libraries across America are experiencing the inevitable consequences of a mental health system that is broken. There are more than 200,000 people in our nation today who are homeless and have a severe mental illness such as schizophrenia or bipolar disorder. On cold days, many of these people will seek shelter at the local public library.

At Ekstrom library on the University of Louisville campus, students compete with the homeless to get on computers. As one student observes, “If the homeless are using property reserved for paying U of L students, then something needs to be done about it.” However, according to library staff, unless the homeless person is causing a disturbance, they are usually left alone.

Chip Ward described the disturbing conditions at the Salt Lake City public library in his poignant op-ed last year.

“People mumbling to themselves, shouting obscenities, and poking nails into celebrity pictures are just some of the problems encountered. Ward observed, “Like every urban library in the nation, the City Library, as it is called, is a de facto daytime shelter for the city's "homeless."

“Homeless” is indeed a misleading term because it clearly focuses on the wrong problem. Most people who remain on our streets over a long period of time do so not because they lack the means to find housing. Rather, up to 70 percent of the homeless are struggling with a serious mental illness, and for them providing housing without treatment is pointless. Remember Nathaniel in California?

Sadly, the general contempt for those who are homeless will only grow as our system continues to ignore the underlying problem. The real solution to this problem will not be found in new library policies. It will be found when our mental health system assumes responsibility to care for people who have mental illnesses so severe they don’t understand they are sick.

Accepting the reality of mental illness

Blogger and writer for National Review, Jennifer Roback Morse comments on Michael Judge’s moving piece about Sonny Iovino in the Wall Street Journal:

“In my view, the problem is that the modern world is so deeply committed to rationality and autonomy that we can not accept the reality of individuals who are not capable of rational thought or of using their autonomy.”

Wall Street Journal: "Free to Die in Iowa"

In today's Wall Street Journal, Michael Judge has a powerful piece about the Sonny Iovino case in Iowa:

After Iovino's death, a spokesman for the VA Medical Center told the Cedar Rapids Gazette, "If somebody doesn't want to be treated, you can't treat them." This is simply not the case. Given his debilitated state, the VA psychiatrist on duty could have forced Iovino to receive the treatment that might have saved his life ...

In fact, Iowa's commitment standard is better than many states', which demand that a person be an "imminent" danger to himself or others. In Iowa, however, to be eligible for AOT a person must lack sufficient judgment to make responsible decisions concerning treatment; and be either (1) a danger to self/others or (2) unable to satisfy the need for "nourishment, clothing, essential medical care, or shelter so that it is likely that the person will suffer physical injury, physical debilitation, or death."

When Iovino was picked up by police just two days prior to his death, he was digging up the earth with his bare hands, talking to himself, barefoot in frigid weather, and huddling near a building's exhaust vent to stay warm. He was at the very least a danger to himself ...

Remember Million-Dollar Murray?

Remember Million-Dollar Murray? So does Washoe County, Nevada. After cycling in and out of the county jail for 10 years, Murray, a homeless man with a mental illness, cost the county an estimated $1 million. He’s also the inspiration for a study completed by the University of Nevada that outlines the cost of homelessness in Washoe County.

According to the Reno Gazette Journal in its report on the study:

The Washoe County Jail is one of the largest providers of mental health services to the homeless, who are further burdening an already-crowded facility. But the jail and court system are the only places for many homeless to receive mental health treatment.

It costs just under $84 a day to house an inmate at the Washoe County Jail. Homeless inmates comprise about 7 percent of the population. In 2004, there were 443 homeless inmates compared with 746 in 2005. Comparatively, 96 of the inmates in 2004 were housed in mental health units while 169 of the homeless inmates in 2005 were housed in the mental health unit. In 2006, it was estimated that homeless inmates cost the county more than $890,000.

Researchers concluded that local officials could save money if they addressed the reasons why people become homeless rather than primarily responding to them during crisis, which leads to costly trips to jail or the emergency room.

"Homelessness is not a problem, it's a symptom," Bartholet said. "If someone is a chronic inebriate and you only provide them with a meal and a place to sleep, you may save their life by keeping them from freezing to death, but you're not doing anything to address the chronic condition they're in.

Yet that’s what the entire state continues to do. Without access to programs like assisted outpatient treatment (AOT), housing will remain nothing more than a band-aid for many of Nevada’s severely mentally ill citizens. The cycle from street to jail will continue. Remember million-dollar Murray?

Homeless shelters are the new mental health facilities

Roughly 150,000 to 200,000 individuals with schizophrenia or bipolar disorder are homeless. In the absence of psychiatric hospitals, homeless shelters are yet another example - along with jails and prisons- of today’s “mental hospitals”.

Out on the streets, people with mental illness and addiction problems are guaranteed neither a home, food, health nor safety.

As [Dennis] Marble [executive director of the Bangor Area Homeless Shelter] and many others see it, the morphing of the homeless shelter into what Marble calls an "underfunded mental health facility" is one of the unintended consequences of the "downsizing" of the state’s mental health institutions, including Bangor Mental Health Institute, now known as the Dorothea Dix Psychiatric Center.

A major complaint of the critics of deinstitutionalization was that adequate community resources were not put into place to support patients after their release. As a result, many did and still do wind up in homeless shelters or jails, which are increasingly hard-pressed to house them adequately.

"I look at some of the folks who come here and it’s pure and simple — they can’t [fend for themselves]," Marble said. "And for me to say the right thing for them is to live their lives in this shelter and that’s their choice? That ends up ringing hollow really fast."

"Residentially challenged"

When you have a home but refuse to live in it, can you really be called "homeless"?

William Royce had a home, and a loving family. But he died in the elements after mental illness robbed him of his ability to make informed choices. A local police department spokesperson called Royce "residentially challenged,' which many, including one letter-writer, called "a new low in political correctness."

But might that actually be the most accurate way to describe someone like William Royce?

In a response via a letter to the editor in the Tallahassee Democrat, William Royce’s father Charles makes this unique argument.

I thought "residentially challenged" was a very correct way to describe the situation, and our family appreciated its use in the newspaper.

This was a young man who wasn't homeless, but he was residentially challenged, and he chose to live where he was found. He was also mentally challenged. He had been diagnosed with schizophrenia and he periodically was affected by that. Whoever coined that phrase, or opted to use that phrase, was very kind in his choice of words and the family appreciated that.

Iowa’s cold-hearted system leads to hypothermia

Photo from Gazette.com: "Personal items and trash are strewn about the homeless camp under Iowa City's Benton Street bridge Thursday. Transient Sonny Anthony Iovino, 55, was found dead from hypothermia under the bridge Wednesday."

The cause of death for Sonny Iovino is officially listed as “hypothermia.”

But it is clear he was a victim of something equally as chilling – a system that bounced him around, seemingly unable (or perhaps unwilling) to help him.

Iovino was a familiar face to Iowa City police, and was repeatedly picked up in the past 5 years on charges like disorderly conduct, public intoxication and simple assault. In fact, “In the first seven days of November, he'd had five encounters with police.”

So fittingly, it seems from news stories that it was the police who tried the hardest to get him help. Yet all the doors were closed to him because he was severely mentally ill and belligerent – a combination that too often fails to ignite compassion.

When officers took Iovino to the VA Center, he was turned away because he was uncooperative.

When the doctor asked to take his vital signs, Iovino made what reports called an inappropriate comment. "I take that as a no," UI Police Officer Alton Poole reported the doctor as saying. The doctor released Iovino back to police.

Yet, when officers then transported him to jail, he was turned away because he was too sick.

Johnson County Sheriff Lonny Pulkrabek told The Gazette the jail won't admit anyone with an immediate medical need. He said the doctor's note indicated Iovino needed hospitalization for mental illness.

He was behaving erratically, and was, in fact, nearly naked in a city where the average temperature in November hovers at 31 degrees. Yet he couldn’t get the help he clearly needed.

The spokesperson for the medical center that released him back to police said hospital officials did all they could:

"If somebody doesn't want to be treated, you can't treat them."

Whether officials are ignorant of state law or willfully ignore it, the result is the same. In reality, Iowa has the option of assisted outpatient treatment, and actually uses its law to a certain extent, but not as much as it could, mainly because of its restrictive eligibility standard.

Iowa's commitment standard basically holds that to be eligible for outpatient treatment or hospitalization, the person must lack sufficient judgment to make responsible decisions concerning treatment AND is either (1) a danger to self/others, including that of serious emotional injuries to family members and others OR (2) unable to satisfy need for nourishment, clothing, essential medical care, or shelter so that it is likely that the person will suffer physical injury, physical debilitation, or death.

From news reports, it sounds like Mr. Iovino met that criteria. Perhaps everyone was tired of trying to help him. Perhaps his attitude and belligerence made him unpleasant to interact with. Perhaps everyone was busy and didn’t want to take the time.

The end result should shame everyone involved.

New idea: mental health courts without the crime

In San Francisco behavioral health courts have been successful in compelling treatment for people with mental illnesses who would otherwise have been in jail or prison. The court allows that when someone with a severe mental illness commits a crime, they are diverted to behavioral health court and ordered to maintain treatment. Failure to maintain treatment sends the person back to criminal court and likely to jail or prison.

The model of connecting the services to the court does work," said Kathleen Connolly Lacey, program director of Citywide. "There has to be a benefit to people to participate. They work harder than they would if they got straight probation."

Here’s the problem. Right now, in San Francisco, court-ordered treatment is only offered AFTER someone commits a crime.

Jennifer Friedenbach, director of the Coalition on Homelessness, said it's one more example of the city offering services to homeless people and the mentally ill only after they become part of the criminal justice system. She and other advocates wonder why these well-regarded services aren't as readily available to mentally ill homeless people outside the courts.

Mayor Newsom: Why are you requiring your citizens with severe mental illnesses to commit a crime before being treated?

Gavin Newsom: Homeless need your compassion

Can Gavin Newsom make San Francisco a leader in compassion for the homeless?

"Newsom," says political strategist Mark Mosher, "has a real opportunity to throw his traditional caution to the wind. Same sex marriage was totally courageous nationally, and somewhat so in the state, but in San Francisco it was a popular and sensible idea. So what are the most difficult issues now?"

Here's a suggestion. The streets of San Francisco.

That suggestion would be a good one for the leader of virtually any American City. At any given time, there are many more people with untreated severe psychiatric illnesses living on America’s streets than are receiving care in hospitals. The uproar is growing. The San Francisco Chronicle’s C.W. Nevius sees an opportunity for Mayor Newsom to make San Francisco an example of compassion by, among other things, implementing Laura’s Law.

Civic leaders familiar with convention bookings are concerned the city is losing business because visitors are spooked by encounters with homeless people and vagrants. Incidents like the one on Oct. 25, when a mentally ill man assaulted a police officer at Justin Herman Plaza, reinforce the perception the streets are not safe.

And it isn't just a dollars and cents issue. As anyone who walks the streets of the city knows, that man is not alone. Wednesday morning, anyone who walked past Sixth and Howard could see a barefoot man with a stick, standing on the corner and screaming unintelligible threats at pedestrians. For him to be on the street, alone and delusional, doesn't serve anyone.

As Dariush Kayhan, executive director of San Francisco Connect, which works with the homeless in the community, says, "If there is any city that has a large number
of mentally disturbed people on the streets, it is San Francisco."

That's why a good first step would be to find funds to implement Laura's Law, the California initiative that empowers local authorities to require mentally disturbed people to submit to a program if they have been refusing to do so voluntarily. Not only is it is a good idea, but San Francisco is in a unique position to do it. Laura's Law must be funded by California counties; the door is open for San Francisco, which is one of the few major cities that is also its own county.

This is a humanitarian issue – getting treatment will save them from a horrific life (the majority of homeless individuals with untreated psychiatric illnesses regularly forage through garbage cans and dumpsters for their food) and repeated victimization. One report on homeless women in San Francisco noted the women were being raped and sexually assaulted at an alarming rate, with some women being raped as many as 17 times. To protect themselves from attack, homeless women were known to wear 10 pairs of panty hose at once and bundle up in layers of clothing.

Randall Hagar, director of Government Affairs for the California Psychiatric Association, put it best:

"This is a humanitarian thing," says Hagar, the Laura's Law supporter. "It can reduce suffering for a group of people who are otherwise unreachable."

Bracing for the cold - and bitter tragedy

Every winter, we read sad news stories about homeless people with severe mental illnesses who fall victim to the elements. While the weather gets blamed for the deaths, the truth is more disturbing: About 1/3 of the nation’s homeless are people with severe mental illnesses.

• Many of these individuals are homeless BECAUSE of their illnesses.
• Most are not being treated for their illness and often the lack of treatment is because they have impaired awareness of their illness.
• The headlines overlook the daily victimization and brutal realities on the streets for people with severe mental illnesses.

Next time you read one of these sad stories, consider the fact that Assisted Outpatient Treatment can prevent tragedy. In New York, 74% fewer participants experienced homelessness while in the AOT program as compared to before they entered the program.

Housing the homeless...who aren't psychotic

In an op-ed in the LA Times, two experts on homelessness and skid row wrote:

The central antidote to homelessness is not a police sweep or a shelter bed. It's housing.

Once housed and given appropriate support and services, formerly homeless people with mental and addiction disabilities -- those for whom we used to think a bowl of soup and a blanket was the best we could do -- have a good chance of staying off the streets.

Certainly, they are right. For many of the people on skid row housing and services are enough. But what about people with mental illnesses so severe they have anosognosia, or a lack of insight into their illness? What about those who are so sick they will never chose mental health treatment? (Remember Nathanial?)

Without assisted outpatient treatment to accompany housing and services, the sickest of the sick are still being ignored.

Forest fires and untreated mental illness

Colorado is a dangerous place to be homeless. In Colorado Springs temperatures hover in the low 20s in December and January.

The freezing temperatures drive many chronically homeless to build fires rather than seek shelters.

Recently in Colorado Springs and Manitou Springs a fire tore through area forests destroying 30 acres and causing $30,000 worth of damage. The fire was believed to be started by a homeless camp.

Dr. Bob Holmes an advocate for the homeless says the fire is a by-product of a bigger problem.

“The bigger problem is an issue that plagues many of the nearly 2,000 homeless people living in Colorado Springs and Manitou Springs, mental illness. We have some mental health issues that are pretty rampant with the chronic homeless. That's why they are chronically homeless. There's not enough treatment available for them."

Homelessness, victimization, suicide, and now forest fires – some of the many consequences of failing to treat severe mental illness.

Staggering stat

A 40 percent increase in the numbers of homeless people isn't drawing much attention - perhaps because the temperature in St. Paul, Minnesota, is a lovely 76 degrees today. Of course, in January that drops to an average of 21 degrees.

For the 40 percent of that group with a diagnosed mental illness, the impending cold weather is just one of the many dangers they face.

A research group says it found 587 homeless people in the [St. Paul] area last fall, a 49 percent increase since 2003. The study found more than 40 percent of the homeless were told within the last two years that they have a serious mental illness such as major depression, schizophrenia or post traumatic stress disorder.

Star of stage, screen, and skid row

Sounds like Hollywood is poised to make another heartwarming movie about someone with mental illness who overcomes the odds. Jamie Foxx is set to play the part of Nathaniel Anthony Ayers, who "like 1% of the population has schizophrenia, sleeps on the sidewalk on skid row. His misfortune is to have the one disease for which there's no poster child, let alone a national telethon."

That quote comes from Steve Lopez, a columnist for the LA Times who has been chronicling Nathanial's life. He has pulled his observations together into a book, which will be the basis for the movie starring Foxx.

Nathanial's family, according to Lopez, couldn't get him to stay in treatment.

As do so many schizophrenics, [his sister] Ayers-Moore says, her brother would improve with medication but then refuse to take it and slip back into his tortured
world.

On October 23, 2005, Lopez noted:

Nathaniel is too sick to know he's sick, so he resists treatment that might give him a shot at a better life, and I now understand the frustration of hundreds of families that have told me in agonizing detail of similar dilemmas.

Lopez wasn't content to write about Nathanial - he wanted to help him. And to get others to help him. And he did. In fact, the time and energy put in by so many at Lopez' behest to help Nathanial is beyond touching.

Yet the effort seemed to shift from rescue to rehabilitation - if we can only get Nathanial to trust us and choose housing, the message became, we can save him. After a full year of engaging him, the experts assessed that he was "close" to moving into the apartment they had secured, and furnished, for him.

Another year on the streets.

What eventually happened to Nathanial will likely make a moving and interesting film. But it should also make us angry.

It took 30 years of homelessness, a background as a world-class musician, and the rapt attention of a renown LA Times columnist to get Nathanial moving along the path - not to treatment, but to possibly, someday, getting treatment. Even then, the goal was to help Nathaniel finally choose housing as a first step to get back some of what he lost in the last 30 years.

At one point in the real-life drama, Lopez asked the prescient question, "With treatment, who knows what he could be capable of?"

Indeed. It is certain Hollywood will slap a happy ending on this story. Expect to see Nathanial at the premiere and for everyone to feel good about lifting this man back up.

Will that make up for society completely neglecting to help him for three decades?

Or make a difference to the thousands like him who still sit on skid row?

Our priorities are a CAT-astrophe

From TAC President E. Fuller Torrey:

I was recently startled to learn that homeless cats are a higher priority than homeless people with schizophrenia.

Alley Cat Allies was organized in 1990 to protect homeless and feral cats by promoting programs for their sterilization and vaccination rather than their euthanization. The organization has three regional offices and a staff and budget three times larger than TAC's.

I like cats, but somewhere along the line our priorities have become badly skewed.

TAC is the only organization trying to promote treatment for individuals with severe psychiatric disorders who are not being treated - the ones who are ending up homeless on the streets and in jails.

Homeless people with untreated mental illnesses certainly deserve our intervention. It is clear we have a lot of work to do, and we need your help to do it.

Mentally Ill, Homeless & in the Snow

That a large proportion of those who are homeless also have a mental illness is beyond debate. Coming up with the exact number of those coping with both homelessness and mental illness is more problematic.

Counting and categorizing the diagnoses of those among a transient population, whose members tend to be without mailing addresses and phones, is a formidable task. A good estimate, however, is that there are 200,000 people with severe mental illness among the 600,000 who live in America’s streets and shelters. This means that one in three people without homes are homeless, at least in part, because of the symptoms of mostly treatable psychiatric illnesses.

The results of an extensive survey of people in Minnesota who are homeless found that 52 percent of them had a serious mental illness, such as severe depression, bipolar disorder or schizophrenia. That percentage is significantly ones found by other researchers. That could be a sign that the prevalence is increasing. A perhaps more likely alternative is that people incapacitated by a severe mental illness are less likely to appreciate that escaping the frigid Minnesota winters can make being homeless at least a little less arduous.

Librarians as mental health care providers?

Nationwide, more than 200,000 people living on the streets have severe mental illnesses. And, at any given time, there are more people with untreated severe psychiatric illnesses living on America’s streets than are receiving care in hospitals. Since these people aren’t receiving treatment, the burden of care falls on groups other than the mental health community. As Chip Ward explains in an op-ed in the LA Times, librarians are one of those de facto care groups.

So where are we to turn for help? Social workers are too few, under funded, overworked and overwhelmed. If a homeless guy is inside the library, then the view is, "Hey, mission accomplished."

Local hospitals also are uncertain allies. They have little room for the indigent mentally ill and often can't get reimbursed for treating them. So they deal with the crisis at hand, fork over some pills and send them on their away.

The cost of this mad system is staggering. Cities that have tracked chronically homeless people estimate that a typical transient can cost taxpayers $20,000 to $150,000 a year. You could not design a more expensive, wasteful or ineffective way of providing healthcare to individuals who live on the street than by having librarians dispense it through paramedics and emergency rooms.

More than the lack of a home

According to a recent report from the National Alliance to End Homelessness, almost three-quarter of a million were homeless in a single month of 2005. Included were 3,415 people who were homeless in Minneapolis. Given the high concentration of those suffering from mental illness among those living in the streets and shelters, it is not surprising that Minneapolis is seeking to alleviate homelessness among that beleaguered population.

The city is offering attractive and purposefully affordable housing with no strings attached. It’s the logical approach – solve homelessness with homes, but that’s not working in Minneapolis because there have been few takers. Fifty vouchers for highly-subsidized housing where given to the Assertive Community Treatment team dedicated to serving the municipality’s homeless population. Since then, only five people with mental illness have taken the chance to move from the streets into a place of their own. The rest remain homeless, braving a Minnesota winter either by choice or – perhaps more likely – by illness.