The Question of Liberty
Perhaps one of the brightest spots of the effects of deinstitutionalization is that the mentally ill have gained a greatly increased measure of liberty. There is often a tendency to underestimate the value and humanizing effects for former hospital patients of simply having their liberty to the extent that they can handle it (even aside from the fact that it is their right) and of being able to move freely in the community. It is important to clarify that, even if these patients are unable to provide for their basic needs through employment or to live independently, these are separate issues from that of having one's freedom. Even if they live in mini-institutions in the community, such as board-and-care homes, the facilities are not locked, and the patients generally have access to community resources.
However, the advocacy of liberty needs to be qualified. A small proportion of long-term, severely disabled psychiatric patients lack sufficient impulse control to handle living in open setting such as board-and-care home or with relatives (Lamb 1980b). They need varying degrees of external structure and control to compensate for the inadequacy of their internal controls. They are usually reluctant to take psychotropic medications and often have problems with drugs and alcohol in addition to their mental illness. They tend not to remain in supportive living situations, and often join the ranks of the homeless. The total number of such patients may not be great when compared to the total population of severely disabled patients. However, if placed in community living arrangements without sufficient structure, this group may require a large proportion of severely disabled patients. However, if placed in community living arrangements without sufficient structure, this group may require a large proportion of the time of mental health professionals, not to mention others such as the police. More important, they may be impulsively self-destructive or sometimes present a physical danger to others.
Furthermore, many of this group refuse treatment services of any kind. For them, simple freedom can result in a life filled with intense anxiety, depression, and deprivation, and often a chaotic life on the streets. Thus they are frequently found among the homeless when not in hospitals and jails. These persons often need ongoing involuntary treatment, sometimes in 24-hour settings such as locked skilled-nursing facilities or, when more structure is needed, in hospitals. It should be emphasized that structure is more than just a locked door; other vital components are high staff-patient ratios and enough high-quality activities to structure most of the patient's day.
In my opinion, a large proportion of those in need of increased structure and control can be relocated from the streets to live in open community settings such as with family or in board-and-care homes, if they receive assistance from legal mechanisms like conservatorship, as is provided in California. But even those who live in a legally structured status in the community, such as under conservatorship or guardianship, have varying degrees of freedom and an identity as a community member.
Some professionals now talk about sending the entire population of chronically and severely mentally ill patients back to the state hospitals, exaggerating and romanticizing the activities and care the patients are said to have received there. To some, reinstitutionalization seems like a simple solution to the problems of deinstitutionalization such as homelessness (Borus 1981; Feldman 1983). But activity and treatment programs geared to the needs of long-term patients can easily be set up in the community, and living conditions, structured or unstructured, can be raised to any level we choose--if adequate funds are made available. The provision of such community resources, adequate in quantity and quality, would go a long way toward resolving the problems of homelessness. In the debate over which is the better treatment setting--the hospital or the community--we must not overlook the patients' feelings of mastery and heightened self-esteem when they are allowed their freedom.
Deinstitutionalization has led to the presence of large numbers of mentally ill persons in the community. At the same time, there are limited amounts of community psychiatric resources, including hospital beds. Society has a limited tolerance of mentally disordered behavior, and the result is pressure to institutionalize persons needed 24-hour care wherever there is room, including jail. Indeed, several studies describe a "criminalization" of mentally disordered behavior (Abramson 1972; Grunberg et al. 1977; Lamb and Grant 1982; Sosowsky 1978; Urmer 1971)--that is, a shunting of mentally ill persons in need of treatment into the criminal justice system instead of the mental health system. Rather than hospitalization and psychiatric treatment, the mentally ill often tend to be subject to inappropriate arrest and incarceration. Legal restrictions placed on involuntary hospitalization also probably result in a diversion of some patients to the criminal justice system.
Studies of 203 county jail inmates, 102 men and 101 women, referred for psychiatric evaluation (Lamb and Grant 1982, 1983) shed some light on the issues of both criminalization and homelessness. This population had extensive experience with both the criminal justice and the mental health systems, was characterized by severe and chronic mental illness, and generally functioned at a low level. Homelessness was common; 39 percent had been living, at the time of arrest, on the streets, on the beach, in missions, or in cheap, transient skid row hotels. Clearly the problems of homelessness and criminalization are interrelated.
Almost half of the men and women charged with misdemeanors had been living on the streets or the beach, in missions, or in cheap transient hotels, compared with a fourth of those charged with felonies. One can speculate on some possible explanations. Persons living in such places obviously have a minimum of community supports; committing a misdemeanor may frequently be a way of asking for help. It is also possible that many are being arrested for minor criminal acts that are really manifestations of their illness, their lack of treatment, and the lack of structure in their lives. Certainly these were the clinical impressions of the investigators as they talked to these inmates and their families and read the police reports.
The studies also found that a significantly larger percentage of inmates aged 35 or older had a history of residence in a board-and-care home, compared with those under age 35. Obviously the older one is, the more opportunity has had to live in different situations, including board-and-care homes. However, in talking with these men and women, other factors emerged: the tendencies of the younger mentally ill person to hold out for autonomy rather than living in a protected, supervised setting, and to resist both entering the mental health system and being labeled as a psychiatric patient, even to the extent of living in a board-and-care home.
Board-and-care homes had been repeatedly recommended to a large number of the younger persons as part of their hospital discharge plans, but they had consistently refused to go. It appeared that eventually many gave up the struggle, at least temporarily, and accepted a board-and-care placement. However, most left the homes after relatively brief periods, many to return to the streets. In some cases, they seemed to want to regain their autonomy, their isolated life-style, and their freedom to engage in antisocial activities. Despite the fact that a high proportion of the study population had serious psychiatric problems, only eight men (out of 102) and five women (out of 101) were living in board-and-care homes at the time of arrest.
Clearly the system of voluntary mental health outpatient treatment is inadequate for this population, who are extremely resistant to it. If they do agree to accept treatment, they tend not to keep their appointments and not to take their medications, and to be unwelcome at outpatient facilities (Whitmer 1980). This is confirmed by our findings, which showed that only 10 percent of the inmates were receiving any form of outpatient treatment, such as medication, at the time of arrest, and that only 24 percent ever received outpatient treatment.
The need for mental health services in jails is apparent (Lamb et al. 1984.) Even so, many mentally ill inmates will not participate in release planning and will not accept referral for housing or treatment. As a result they are released to the streets to begin anew their chaotic existences characterized by homelessness, dysphoria and deprivation. To work with this population of mentally ill in jails is to be impressed by their need for ongoing involuntary treatment.
The majority of chronically mentally ill persons live with their families or in sheltered living situations such as board-and-care homes. Some live in situations such as single-room-occupancy hotels or otherwise alone. Many are in and out of hospitals. Some are continuously homeless, and some intermittently so. While a minority of the total population of chronically mentally ill are homeless at any given time, very substantial numbers of persons are involved, and homelessness of the chronically mentally ill is a critical nationwide problem.
What have we learned from our experiences with more than two decades of deinstitutionalization? First of all, it has become clear that what is needed is a vast expansion of community housing and other services and a whole revamping of the mental health system to meet the needs of the chronically mentally ill. Markedly increased funding is needed to increase the quality, quantity and range of housing and other services, improve the quality of life for this population, and meet their needs for support and stability. The availability of suitable services should make it possible to attract many of the homeless to stable living arrangements and retain them there.
Many of the chronically mentally ill are not able to find or retain such community resources such as housing, a stable source of income, and treatment and rehabilitation services. The need for monitoring and treating these patients by means of aggressive case management has become increasingly apparent. Aggressive case management for all of the chronically mentally ill, given the availability of adequate housing and other resources, would probably minimize homelessness.
It is one of the injustices of deinstitutionalization that, compared to the developmentally disabled, the chronically mentally ill in the community do not fare well in terms of funding, housing and services. Surely the mentally ill should be given equal priority. The success of deinstitutionalization for the developmentally disabled, however, does demonstrate what can be accomplished when there is determined advocacy and adequate funding and community resources.
We have learned in this era of deinstitutionalization that many of the homeless mentally ill feel alienated from both society and the mental health system, that they are fearful and suspicious, and that they do not want to give up what they see as their autonomy, living on the streets where they have to answer to no one. They may be too acutely and chronically mentally ill and disorganized to respond to our offers of help. Their tolerance for closeness and intimacy is very low, and they fear they will be forced into relationships they cannot handle. They may not want a mentally ill identity, may not wish to or are not able to give up their isolated life-style and their anonymity, and may not wish to acknowledge their dependency. Thus we are dealing with an extremely difficult and challenging population.
As with most problems, we have learned that there are no simple and universal solutions to the problems of homelessness. Let us take the shelter approach as an example. Some of the chronically mentally ill will accept food and shelter, but nothing else, and sooner or later return to the streets, despite the efforts of our most sensitive clinicians. A few will not accept simple shelter, even with no conditions attached.
Certainly we must provide emergency shelter, but we also need to be aware that this is a symptomatic approach. Instead our primary focus should be on the underlying causes of homelessness, and we should work to provide a full range of residential placements, aggressive case management, changes in the legal system, a ready availability of crisis intervention including acute hospitalization, and other crucial community treatment and rehabilitation services.
We have also learned that some of the chronically mentally ill, because of their personality problems, their lack of internal controls, and their resort to drugs and alcohol, will not be manageable, or welcome, in open settings, such as with family or in board-and-care homes, or even in shelters. Some will need more structure and control; they may need involuntary treatment in a secure intermediate or long-term residential setting or in the community, facilitated by mechanisms such as conservatorship or mandatory aftercare. Such intervention should not be limited to those who can be proven to be "dangerous," but should be extended to gravely disabled individuals who do not respond to aggressive case management and are too mentally incompetent to make a rational judgment about their needs for care and treatment. In this way we can help those homeless mentally ill who are unwilling to accept our assistance and whose self-destructive tendencies, personality disorganization, and inability to care for themselves result in lives lived alternately in jails, in hospitals, and on the streets. In some cases such intervention is the only act of mercy left open to us.
We have learned that we must accept patients' dependency when dealing with the chronically mentally ill. And we must accept the total extent of patients' dependency needs, not simply the extent to which WE wish to gratify these needs. We have learned, or should have learned, to abandon our unrealistic expectations and redefine our notions of what constitutes success with these patients. Sometimes it is returning them to the mainstream of life; sometimes it is raising their level of functioning just a little so they can work in a sheltered workshop. But oftentimes success is simply engaging patients, stabilizing their living situations, and helping them lead more satisfying, more dignified, and less oppressive lives.
The reluctance of mental health professionals and society to fully accept the dependency of this vulnerable group, inadequate case management systems, the preference of many mental health professionals to work with more "healthy" and "savory" patients, and an ideology that "coercive" measures should be used only in cases of "extreme danger" leave the homeless mentally ill in extreme jeopardy. If deinstitutionalization has taught us anything, it is that flexibility is all important. We must look objectively at the clinical and survival needs of the patients and meet those needs without being hindered by rigid ideology or a distaste for dependency.