Editorial Impressions of the National Hearing on Severe Mental Illness and Homelessness
Another witness, a previously successful executive, spoke of the devastating effects of the stigma of mental illness on her own life. As she began to experience symptoms of mental illness, her friends and her co-workers showed anger, telling her to “pull herself together.” She lost her job, her home, her savings, and her husband. She was homeless for a while. The woman reported trying 26 different medications under medical supervision before she found one that was helpful. Now, she is rebuilding her career and her life. Alan Lescher, Acting Director of NIMH, stated that “homeless people with severe mental illnesses are among the most vulnerable, disabled, and underserved members of our society.” Cushing Dolbeare emphasized that “no one should be homeless in this country, even for a night.” She cited affordability of housing as a primary problem, noting the general availability of rental housing units. For example, she reported that the Fair Market Rents (FMR) in 1991 for one-bedroom units with utilities ranges from a high of $660 in Massachusetts to a low of $340 in Alabama, with a median of $430. She also noted that FMRs are out of reach for more than half of all renter households in all states. Affordable housing is becoming a problem for greater numbers of families, the young, and the elderly. A number of witnesses stressed that more housing is needed for homeless persons. They also need jobs, health and dental care, and treatment for mental illness and substance abuse problems. Lewis Judd, Chair of the NMHLF, stated that the homeless mentally ill face a “double burden” because the mentally ill are often excluded from programs because they are homeless, and the homeless are excluded from programs because they are mentally ill. In Judd’s view, “‘just as warehousing the mentally ill persons in state hospitals in the first half of the 20th century made no sense, locking them up in jails, sedating them in nursing homes, or ignoring them on our city streets makes no sense as we approach the 21st century.”The psychiatrist, E. Fuller Torrey, noted that “after years of deinstitutionalization, it is time to go back to the drawing board and reevaluate the economics of the mental
I
T HAS BEEN ESTIMATED that
on any given night, approximately 600,000 persons in the United States are homeless; 30% are estimated to be mentally ill. Approximately 13% of the homeless are single women; about one-third to one-half of homeless adult men are veterans. The numbers of homeless families and adolescents in America is growing. It is estimated that approximately one-third of the homeless are families; one in every four homeless persons is a child. On September 5 , 1991, a National Hearing on Severe Mental Illness and Homelessness convened in Chicago to focus national attention on the needs of the severely mentally ill and homeless and to learn from scientists, practitioners, and consumers about knowledge gaps and service needs. The hearing was cosponsored by the National Advisory Mental Health Council of the National Institute of Mental Health (NIMH) and the National Mental Health Leadership Forum (NMHLF), with the participation of the Federal Interdepartmental Task Force on Homelessness and Severe Mental Illness. Over one hundred witnesses provided testimony. As one of the hearing officers, I was reminded of how rapidly knowledge of mental illness is advancing, while at the same time how very far we have to travel to reduce stigma, to develop effective treatments, and to transform service delivery systems to better serve the mentally ill. The actor Rod Steiger was eloquent in his testimony as he described his own battle with severe depression. “There were days when I would get up in the morning, say hello to my wife, sit by the ocean for 12 hours, say good night, and go to bed.” He gave no thought to care of himself, including personal hygiene. and he thought of suicide. He described the oncoming symptoms of mental illness as being “like a fog that crept into my head.” He also described the considerable efforts it took to get relief, once he had made the decision to get help, by going to several professionals and trying a number of medications before one was found that worked for him to relieve the distressing symptoms. He said he accepted the invitation to speak at the hearing to call attention to mental illness as a treatable disorder.
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health services system.’‘ Jan Holcomb of the Mental Health Association of Illinois said that our system of care “not only remains tragically flawed but also inflicts additional damage on people with serious mental illness. many of whom will consequently suffer the indignity and brutality of homelessness. warehousing. or incarceration.” Laurie Flynn. Executive Director of the National Alliance for the Mentally 111. concluded that “no one would ever think of rushing a heart attack victim to jail. Why then do we silently allow homeless mentally ill people to suffer that fate’?’’I t has been estimated that 9.5% to 27% of persons who enter the penal system are mentally i l l or mentally retarded. Carl Amino. of the Cook County Department of Corrections. stated that ”one of the unfortunate results of an overall discontinuity ofcommunitybased psychiatric care is that a segment of the chronically mentally ill population is reinstitutionalized repeatedly in the criminal justice system.” Howie the Harp, a name given him when he was a homeless street musician. emphasized the importance of empowerment for homeless persons. He asked that the focus be on providing the homeless and the mentally i l l with the services they want and collaborating with them to develop self-help programs. He said that shelters are becoming institutions in themselves and often are part of the problem of He stressed the need for multiple services and stated that. like most adults. homeless people do not want to live in institutional settings that restrict their freedom. autonomy, and privacy. One young man. diagnosed with mental illness at the age of 12 years. described years of abuse during which he was locked in his room where he banged his head against the wall to stop the hallucinations. This was followed by a period of homelessness in which he drifted from place to place. His voice broke as he testified that he once shared a doghouse with a dog. the only shelter he could find. In a conversation with a father and his daughter who had testified at the hearing, the father commented that recently he was in the kitchen with his daughter when she got a bread knife out of the drawer to cut some bread. He said he told her, “1 feel so good to see you doing something like cutting bread with that knife rather than cutting yourself.” His daughter smiled knowingly. Both understood that she had made considerable progress. Although this family had resources that many families do not, they too suffered the pangs of burn out and long struggles along the way in trying to find help for
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their daughter. Another mother of a mentally ill son, and a national advocate for families of the homeless and missing mentally ill, reported that she was “appalled’ to learn that few people really understood or seemed to care about the struggles of the families of the homeless and missing mentally ill. She said these families are often viewed with suspicion and contempt and stereotyped as uncaring and unconcerned. She continued, saying that these families are “tired and burned out. They are feeling lost and hopeless. They are dealing with a system that simply isn’t working for them, and they are receiving no support.” Themes that were often repeated in the testimony were: (a) the need for improved coordination of services, (b) the importance of including consumers on case management teams. and (c) the availability of multiple services in one setting so the consumer does not have to work with multiple agencies to receive physical health care, mental health care, substance abuse services, and job assistance. Consumers who testified stressed the importance of their families in providing continued support and caring, and committed health care providers who did not give up. Progress is being made through research. Lewis Judd emphasized that approximately 95% of what we currently know about the normal and abnormal structure of the brain has been learned in the past 10 years. The 1990s has been recognized as the Decade of the Brain by the U.S. Congress. and brain research continues to accelerate. Advances in knowledge can be expected to enhance our understanding and treatment of a variety of disorders. Increased attention also is needed in mental health services research. We still have a long way to go to advance knowledge and to devise effective mental health service delivery systems that are compassionate and effective. Recommendations from the National Hearing on Severe Mental Illness and Homelessness will be presented in 1992 in a special report requested by the Appropriations Committees of the U . S . Congress. I talked to several witnesses who wondered whether the issues raised and the recommendations made would make any difference. The reactions of the professional, advocacy, and consumer communities to the dialogue and recommendations of this hearing may influence whether it does, in fact, make a difference. SUE M A K Q ~ BISHOP, IIS PHD. R N , FAAN
Another witness, a previously successful executive, spoke of the devastating effects of the stigma of mental illness on her own life. As she began to experience symptoms of mental illness, her friends and her co-workers showed anger, telling her to “pull herself together.” She lost her job, her home, her savings, and her husband. She was homeless for a while. The woman reported trying 26 different medications under medical supervision before she found one that was helpful. Now, she is rebuilding her career and her life. Alan Lescher, Acting Director of NIMH, stated that “homeless people with severe mental illnesses are among the most vulnerable, disabled, and underserved members of our society.” Cushing Dolbeare emphasized that “no one should be homeless in this country, even for a night.” She cited affordability of housing as a primary problem, noting the general availability of rental housing units. For example, she reported that the Fair Market Rents (FMR) in 1991 for one-bedroom units with utilities ranges from a high of $660 in Massachusetts to a low of $340 in Alabama, with a median of $430. She also noted that FMRs are out of reach for more than half of all renter households in all states. Affordable housing is becoming a problem for greater numbers of families, the young, and the elderly. A number of witnesses stressed that more housing is needed for homeless persons. They also need jobs, health and dental care, and treatment for mental illness and substance abuse problems. Lewis Judd, Chair of the NMHLF, stated that the homeless mentally ill face a “double burden” because the mentally ill are often excluded from programs because they are homeless, and the homeless are excluded from programs because they are mentally ill. In Judd’s view, “‘just as warehousing the mentally ill persons in state hospitals in the first half of the 20th century made no sense, locking them up in jails, sedating them in nursing homes, or ignoring them on our city streets makes no sense as we approach the 21st century.”The psychiatrist, E. Fuller Torrey, noted that “after years of deinstitutionalization, it is time to go back to the drawing board and reevaluate the economics of the mental
I
T HAS BEEN ESTIMATED that
on any given night, approximately 600,000 persons in the United States are homeless; 30% are estimated to be mentally ill. Approximately 13% of the homeless are single women; about one-third to one-half of homeless adult men are veterans. The numbers of homeless families and adolescents in America is growing. It is estimated that approximately one-third of the homeless are families; one in every four homeless persons is a child. On September 5 , 1991, a National Hearing on Severe Mental Illness and Homelessness convened in Chicago to focus national attention on the needs of the severely mentally ill and homeless and to learn from scientists, practitioners, and consumers about knowledge gaps and service needs. The hearing was cosponsored by the National Advisory Mental Health Council of the National Institute of Mental Health (NIMH) and the National Mental Health Leadership Forum (NMHLF), with the participation of the Federal Interdepartmental Task Force on Homelessness and Severe Mental Illness. Over one hundred witnesses provided testimony. As one of the hearing officers, I was reminded of how rapidly knowledge of mental illness is advancing, while at the same time how very far we have to travel to reduce stigma, to develop effective treatments, and to transform service delivery systems to better serve the mentally ill. The actor Rod Steiger was eloquent in his testimony as he described his own battle with severe depression. “There were days when I would get up in the morning, say hello to my wife, sit by the ocean for 12 hours, say good night, and go to bed.” He gave no thought to care of himself, including personal hygiene. and he thought of suicide. He described the oncoming symptoms of mental illness as being “like a fog that crept into my head.” He also described the considerable efforts it took to get relief, once he had made the decision to get help, by going to several professionals and trying a number of medications before one was found that worked for him to relieve the distressing symptoms. He said he accepted the invitation to speak at the hearing to call attention to mental illness as a treatable disorder.
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health services system.’‘ Jan Holcomb of the Mental Health Association of Illinois said that our system of care “not only remains tragically flawed but also inflicts additional damage on people with serious mental illness. many of whom will consequently suffer the indignity and brutality of homelessness. warehousing. or incarceration.” Laurie Flynn. Executive Director of the National Alliance for the Mentally 111. concluded that “no one would ever think of rushing a heart attack victim to jail. Why then do we silently allow homeless mentally ill people to suffer that fate’?’’I t has been estimated that 9.5% to 27% of persons who enter the penal system are mentally i l l or mentally retarded. Carl Amino. of the Cook County Department of Corrections. stated that ”one of the unfortunate results of an overall discontinuity ofcommunitybased psychiatric care is that a segment of the chronically mentally ill population is reinstitutionalized repeatedly in the criminal justice system.” Howie the Harp, a name given him when he was a homeless street musician. emphasized the importance of empowerment for homeless persons. He asked that the focus be on providing the homeless and the mentally i l l with the services they want and collaborating with them to develop self-help programs. He said that shelters are becoming institutions in themselves and often are part of the problem of He stressed the need for multiple services and stated that. like most adults. homeless people do not want to live in institutional settings that restrict their freedom. autonomy, and privacy. One young man. diagnosed with mental illness at the age of 12 years. described years of abuse during which he was locked in his room where he banged his head against the wall to stop the hallucinations. This was followed by a period of homelessness in which he drifted from place to place. His voice broke as he testified that he once shared a doghouse with a dog. the only shelter he could find. In a conversation with a father and his daughter who had testified at the hearing, the father commented that recently he was in the kitchen with his daughter when she got a bread knife out of the drawer to cut some bread. He said he told her, “1 feel so good to see you doing something like cutting bread with that knife rather than cutting yourself.” His daughter smiled knowingly. Both understood that she had made considerable progress. Although this family had resources that many families do not, they too suffered the pangs of burn out and long struggles along the way in trying to find help for
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their daughter. Another mother of a mentally ill son, and a national advocate for families of the homeless and missing mentally ill, reported that she was “appalled’ to learn that few people really understood or seemed to care about the struggles of the families of the homeless and missing mentally ill. She said these families are often viewed with suspicion and contempt and stereotyped as uncaring and unconcerned. She continued, saying that these families are “tired and burned out. They are feeling lost and hopeless. They are dealing with a system that simply isn’t working for them, and they are receiving no support.” Themes that were often repeated in the testimony were: (a) the need for improved coordination of services, (b) the importance of including consumers on case management teams. and (c) the availability of multiple services in one setting so the consumer does not have to work with multiple agencies to receive physical health care, mental health care, substance abuse services, and job assistance. Consumers who testified stressed the importance of their families in providing continued support and caring, and committed health care providers who did not give up. Progress is being made through research. Lewis Judd emphasized that approximately 95% of what we currently know about the normal and abnormal structure of the brain has been learned in the past 10 years. The 1990s has been recognized as the Decade of the Brain by the U.S. Congress. and brain research continues to accelerate. Advances in knowledge can be expected to enhance our understanding and treatment of a variety of disorders. Increased attention also is needed in mental health services research. We still have a long way to go to advance knowledge and to devise effective mental health service delivery systems that are compassionate and effective. Recommendations from the National Hearing on Severe Mental Illness and Homelessness will be presented in 1992 in a special report requested by the Appropriations Committees of the U . S . Congress. I talked to several witnesses who wondered whether the issues raised and the recommendations made would make any difference. The reactions of the professional, advocacy, and consumer communities to the dialogue and recommendations of this hearing may influence whether it does, in fact, make a difference. SUE M A K Q ~ BISHOP, IIS PHD. R N , FAAN
