The plight of the mentally ill homeless is receiving more attention this month through two sources - New York City Mayor Edward Koch, and Congress - which passed a homeless aid bill in the last session. Mayor Koch ignited fierce debate when he announced that beginning Oct. 1, New York would begin a policy of bringing the mentally ill homeless in off the streets, even if they are not considered to be endangering their own health. (Up to now, placing the homeless involuntarily in emergency hospitalization required that consideration). The policy will affect an estimated 500 mentally ill homeless in the city.
Critics argue that unless the current system is beefed up to handle the influx of new patients, the Koch proposal will simply mean further inadequate care for the homeless.
On a different front, provisions in the federal homeless aid bill have brought federal, state, and local mental health advocates together to plan how to carry out parts of that bill aimed specifically at the mentally ill homeless. Though most admit the aid is still small compared to the need, many are cautiously optimistic that it could begin to spur a more comprehensive look at how to help those suffering on the street.
Marilyn is a fortunate one. Although she appears to have mental health problems, this intense, well-educated woman has found a temporary and safe sanctuary in the Casa Maria shelter for homeless women and children in Milwaukee.
Marilyn (not her real name) says she has done a variety of live-in jobs. She says she had steady work for nearly 20 years, until her father died in 1979. Now she says she can work only a couple months at a time. At first she says she doesn't consider herself homeless. But as she tells of the other shelter she has stayed in, and how she keeps all her belongings in a locker at the bus depot, Marilyn says she guesses she is homeless.
``This summer has been about the worst,'' says Marilyn, who breaks into a lovely smile occasionally.
Others in Milwaukee are not as lucky. Bag ladies sleep in church doorways, and though many are streetwise enough to protect themselves, there have been rapes. Tom Hickey, project manager of the Health Care for the Homeless Program, says nearly 90 percent of the women living on the streets here have mental health problems.
One of the reasons for the large, visible population of mentally ill homeless was the move to ``deinstitutionalize'' patients in mental hospitals, beginning in the late 1950s. The numbers increased through the '60s and '70s. Many have adjusted quite well in society; others have slipped through the cracks.
Koch's move is applauded by some and looked at suspiciously by others both in New York and around the country.
``It was brave of [Koch] to address it the way he did,'' says Stephen Somers of the Robert Wood Johnson Foundation, which has been involved in funding programs to aid the mentally ill. But, he says, ``It is clear that the No. 1 service not provided is decent, permanent shelter.'' The 500 or more people who may be affected by the Koch ruling will not necessarily end up in the appropriate setting. What needs to be done requires coordination between federal, state, and local governments.
``There is a need for a broader plan than sweeping the homeless off the street into emergency rooms,'' says Irene Shifren Levine of the National Institute for Mental Health (NIMH).
Dr. Levine points out that provisions in the homeless aid bill provide for mental health block grants and for demonstration grants, administered by NIMH, for model projects of comprehensive services. Requirements for the NIMH grants will be homeless outreach, which may include nontraditional settings in shelters and on the street; long-term case management, where an individual will be assessed, housing will be found, further care will be ensured; emergency, transitional, and long-term housing; and coordination.
``The funds are very modest,'' she says. Emergency aid will not solve the problem of homeless people on the streets. That will require changes in the system, in the way low-income housing is provided, and the way mental health care is given.