Outcasts on Main Street: homelessness and the mentally ill.

Attempts to help homeless people with severe mental illnesses rebuild their lives have to address and improve all aspects of their situations. There is growing consensus that an array of basic life supports (e.g., food, clothing, and shelter) and specialized services is required to respond adequately to the needs of this extremely disadvantaged population. The ideal service system is a comprehensive and integrated system of care with designated responsibility, accountability, and adequate fiscal resources.

No matter how many agencies or individual providers are involved, one must be identified as the lead authority at each level of government, accountable for ensuring access, appropriateness, and continuity of services. Moreover, people who are homeless and severely mentally ill require a system of care that they can maneuver, one that is capable of a coherent response to their many needs. Integrating administrative, fiscal, and clinical authority is one of the most problematic service system issues related to this population. While there is a growing knowledge base of research and experience that can be used by states and communities in designing strategies for systems integration, the ultimate form will have to reflect local needs, resources, and priorities.

Most severely mentally ill people who are homeless find it difficult, if not impossible, to improve their lives appreciably on their own. Disorientation, mistrust, fear of rehospitalization, ignorance, lack of motivation, language problems, and poverty keep them from enlisting the aid of others and maintaining contact with many of the resources that significantly might enhance their well-being. Moreover, many are unwilling and / or unable to accommodate to the conventions of traditional service systems, such as keeping appointments for office visits (which also requires accessible transportation).

Service providers, therefore, must meet homeless individuals on their own terms and their own turf These workers should address immediate survival needs (such as food, clothing, and shelter) and provide sustained treatment and support, based on ongoing assessment of clinical conditions and needs. The process of engaging homeless people is time-consuming, protracted, and staff-intensive. Nevertheless, by offering patient, persistent, and continuing contacts over relatively long periods of time, outreach workers can establish the trusting relationships that are essential to engage and help mentally ill people living on the streets. Outreach strategies also can be used to help those in shelters move into more stable housing situations that are linked with supportive services.

Street outreach must include the capacity for an emergency response as well as engagement. Homeless mentally ill individuals often are found living in life-threatening circumstances and / or precarious locations. For example, the New York City Transit Police estimate that 5,000 people lived in the bowels of the city's subway system in 1989, many of them persons with severe mental illnesses. That year alone, 79 individuals either were electrocuted or hit by trains. Similarly, some homeless mentally ill individuals living on the streets are unable or unwilling to go indoors in below-freezing temperatures. For reasons such as these, crisis outreach teams should be available to evaluate individuals and transport them, if necessary, to emergency or inpatient services. Backup medical and psychiatric support is essential to ensure access to involuntary treatment when necessary.

Drop-in centers, which are generally small, accessible, store-front locations, often are effective in engaging those who typically are not reached by other service interventions. Distinguished from more formal programs by their casual accessibility, these centers can offer a place to sit during the day, sleep at night, or both. They particularly are inviting to many homeless mentally ill individuals because they ask few questions and make no demands. Like other outreach efforts, they often become a bridge to the more formal service delivery and / or shelter network.

Another essential service system component is case or integrated care management. The goals include enhancing continuity of care, access to services, and efficiency and accountability of service provision and integration. Essentially, there must be a sustained relationship with someone who knows each client as an individual and understands his or her needs and how to address them.

An integrated care manager also can help the client to negotiate the maze of disparate Federal, state, and local services to obtain benefits and entitlements; assist with and arrange access to health and dental care, housing, and transportation; coordinate appointments and monitor compliance with mental health and substance abuse treatments; and see that the client receives timely, appropriate services. Care management may include assessing the need for a representative payee - a responsible person selected to manage disability and welfare incomes for clients deemed incapable of doing so.

Effective integrated care management can improve the over-all functioning of homeless people with severe mental illnesses, reduce their contact with police and crisis and inpatient services, and stimulate closer involvement with families and housing providers. By establishing a continuing relationship, and encouraging and facilitating more appropriate use of community-based services, this form of integrated care management also may lessen the revolving door of rehospitalization and homelessness.

Providing shelter

For many mentally ill people who have been living on the streets, the transition to stable housing best is made in stages, starting with a small, highly supportive environment where they can feel at ease and out of danger and are subject to relatively few demands. Most communities offer shelters as a first point of refuge for all homeless people, but these often are not well-suited to people with severe mental illnesses, and vice versa. Some shelters will not admit people who are psychotic and unwilling to accept treatment immediately; others exclude persons who use alcohol or other drugs. From the perspective of severely mentally ill people who are accepted in large public shelters, these facilities often are frightening places - crowded sites that offer no safety, peace, or privacy, where assault and theft are common, and these vulnerable...