HOMELESS AND HELPLESS: HOW THE UNITED STATES HAS FAILED THOSE WITH SEVERE AND PERSISTENT MENTAL ILLNESS.

AuthorGorfido, Ashley
  1. INTRODUCTION 108 II. BACKGROUND 111 A. The History of State Hospital Care 111 B. A Shift into the Community 113 C. The Role of Social Security 116 D. Modern Homelessness 116 E. Society's Understanding of Homelessness and Mental 117 Illness III. ANALYSIS 121 A. Lack of Effective Treatment 122 i. Solutions 123 B. SSDI and SSI 123 i. Solutions 125 C. The Challenge of Housing 126 i. Solutions 126 D. What America Sees 127 i. Solutions 128 IV. CONCLUSION 129 I. INTRODUCTION

    The United States has failed its citizens who suffer from severe and persistent mental illness (SPMI). Homelessness is one of the most obvious manifestations of this failure. The combination of a lack of effective treatment, inadequate entitlement programs, such as Social Security Disability Insurance, and subpar housing options form systemic barriers that prevent people suffering from mental illness from being able to obtain adequate housing. Cultural beliefs within the United States regarding who is homeless and what homelessness means also play a significant role in the development of positively impactful social welfare programs.

    SPMI refers to mental disorders that affect people in early adulthood and have significant effects on family relations, educational attainment, occupational productivity, and social role functioning over the individual's life span. (1) Mental health disorders that fall into this category include schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, autism, and obsessive-compulsive disorder. (2) These disorders affect roughly five million people and represent a significant percentage of the clients of mental health services. (3) It has been estimated that the economic impact of SPMI in the United States is $148 billion per year and 10% of the annual direct health care costs. (4)

    Current models of care for mental health treatment do not adequately address mental illness. (5) "Mental illness accounts for about one-third of the world's disability caused by all adult health problems, resulting in enormous personal suffering and socioeconomic costs." (6) Mental illness is closely associated with poverty which can lead to homelessness. (7) People suffering from SPMI often receive no treatment or inadequate treatment for their mental illness. (8) There is also a growing gap between mental health care needs and available services. (9) Social stigma associated with seeking mental health services often deters people with SPMI from seeking serves, and people suffering from SPMI often have complex needs that are difficult to address within the current treatment models. (10)

    "Homelessness among persons with severe and persistent mental illness is the most visible manifestation of failures in mental health policy and in other areas of public policy." (11) The average age of onset of SPMI ranges from late teens through early 20s. (12) "Working-age Americans with disabilities are much more likely to live in poverty than other Americans are." (13) People suffering from SPMI rely on Social Security Insurance (SSI) and/or Social Security Disability Insurance (SSDI) for income. (14) In the best case scenario, the income received will put the individual at the poverty line. (15) In 2008, the average SSI payment was $439 per month and the average SSDI payment was $1,063 per month. (16) Poverty-level income does not support decent housing. "The average rent on a modest efficient apartment [is] equal to 96% of the monthly Social Security Insurance payment." (17)

    People suffering from SPMI represent roughly 45% of the homeless population in the United States. (18)

    Loss of housing represents a profound breach in the fabric of normative expectations and social structures that bind individuals to any society. Few situational changes connote so many interrelated losses--in physical security, personal identity, social status, and community connections--particularly among persons with a history of severe mental illness. (19) Without adequate income to support stable housing, people with SPMI have to rely on public housing programs for housing services. "The U.S. Department of Housing and Urban Development (HUD) administers Federal aid to local housing agencies (HAs) that manage the housing for low-income residents at rents they can afford." (20) Placement in subsidized housing reduces, but does not eliminate, the risk of housing loss for people suffering from homelessness and SPMI. (21) Studies show 16% to 25% of people suffering from homelessness and SPMI lose their housing one year after obtaining it, and 50% after five years of having housing. (22)

    Arguably, the biggest problem for people with SPMI who are also experiencing homelessness is that America does not like them. The demographics of this population encompass those who have not been seen in a favorable light throughout the history of the United States, and those who have been subject to significant discrimination. Society tends to understand homelessness as the result of personal deficiencies like SPMI. (23) Homelessness has been an issue of national concern among the media, academia, and policy makers since the 1960s, and is a historical social issue that has existed since the 1700s. (24) The focus in remedying homelessness has been on explaining the causes and developing more effective prevention and intervention strategies. (25) "A critical point in the debate is whether homelessness results from individual or structure-level factors. For instance, is homelessness the result of personal disabilities such as substance abuse and poor decisions or is it the result of larger systemic factors such as insufficient affordable housing and employment opportunities?" (26) Policy makers attribute the causes of homelessness to individual factors. This blame-shift has resulted in a failure to address the glaring issues that exist within the United States' social welfare programs, e.g. housing and SSI and SSDI. (27)

    Part II of this Note will review the history of treatment for persons with SPMI, specifically how that treatment has evolved, the history of federal policies regarding SSI, SSDI and housing, and societal beliefs regarding homelessness and mental illness that have impacted policy making decisions. Part III of this Note will look at these same areas from a current perspective and will address the current issues and some possible solutions. Part IV of this Note will discuss how lack of effective treatment, poor disability programs, and the need for better housing options work together to form systemic barriers for people with SPMI. Part IV will also address how the cultural beliefs in the United States regarding people who have SPMI and are homeless serve as an independent barrier to policy change. Ultimately, this Note argues that homelessness is a product of system failures rather than individual factors.

  2. BACKGROUND

    1. The History of State Hospital Care

      Mental illness is not a new problem, and the methods for caring for people suffering from SPMI have had advances and setbacks. (28)

      The history of psychiatric hospitals was once tied tightly to that of all-American hospitals. Those who supported the creation of the first early-eighteenth-century public and private hospitals recognized that one important mission would be the care and treatment of those with severe symptoms of mental illnesses. (29) Most people suffering from SPMI during this time remained with their families and received treatment at home. (30) Communities showed significant tolerance for what would be considered strange thoughts and behaviors; however, some people suffering from SPMI seemed too violent or disruptive to remain at home or in the community. (31) Public almshouses and private hospitals created separate wards for people suffering from SPMI. (32)

      The nineteenth-century brought European ideas regarding treatment and care for SPMI to the United States. (33) "'Moral treatment' promised a cure for mental illnesses to those who sought treatment in a very new kind of institution - an 'asylum.'" (34) Moral treatment originated in the late eighteenth century, and was based on the assumption that mental illness could be alleviated if patients were treated in a considerate and friendly manner, if they had opportunities to discuss their troubles, if they actively engaged in some form of communal life, and if their interests were stimulated. (35) Moral treatment rejected the use of harsh restraints and long periods of isolation that were used as treatment methods to manage destructive behaviors of mentally ill individuals. (36)

      Moral treatment was established at some institutions, but "the general sense of social responsibility toward the unfortunate was not very strong during this era." (37) People suffering from SPMI often ended up in jail or local poorhouses, "undifferentiated from offenders and the destitute poor." (38) Dorothea Dix brought attention to the awful treatment of this population and was a key figure in the building and expanding of specialized mental hospital facilities. (39) "The mental hospital system marked a real advance from the indiscriminate practices that preceded it. The evidence is that the conditions mental hospitals provided were relatively humane and therapeutic." (40) By the 1870's nearly every state had one or more such treatment facilities funded by state tax dollars. (41)

      The industrial revolution brought social conditions that increased the tendency to hospitalize those who could not adapt to the new demands of the time. (42) Family structures changed during this time due to changes in the nature of work, family life, and community tolerance for bizarre behavior or incapacity. (43) These changes made it difficult to maintain old and disabled members within the family. (44) As the number of older people increased due to an increase in life expectancy, the mental hospital became a refuge for the elderly. (45) This resulted in mental...

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