Deinstitutionalization and the Homeless Mentally Ill
by H. Richard LambIs deinstitutionalization the cause of homelessness? Some would say yes and send the chronically mentally ill back to the hospitals. A main thesis of this chapter, however, is that problems such as homelessness are not the result of deinstitutionalization per se but rather of the way deinstitutionalization has been implemented. It is the purpose of this chapter to describe these problems of implementation and the related problem of the lack of clear understanding of the needs of the chronically mentally ill in the community. The discussion then turns to some additional unintended results of these problems, such as the criminalization of the mentally ill that usually accompanies homelessness. The chapter concludes with some ways of resolving these problems.
To see and experience the appalling conditions under which the homeless mentally ill exist has a profound impact upon us; our natural reaction is to want to rectify the horrors of what we see with a quick, bold stroke. But for the chronically mentally ill, homelessness is a complex problem with multiple causative factors; in our analysis of this problem we need to guard against settling for simplistic explanations and solutions.
For instance, homelessness is closely linked with deinstitutionalization in the sense that three decades ago most of the chronically mentally ill had a home--the state hospital. Without deinstitutionalization it is unlikely there would be large numbers of homeless mentally ill. Thus in countries such as Israel, where deinstitutionalization has barely begun, homelessness of the chronically mentally ill is not a significant problem. But that does not mean we can simply explain homelessness as a result of deinstitutionalization; we have to look at what conditions these mentally ill persons must face in the community, what needed resources are lacking, and the nature of mental illness itself.
With the mass exodus into the community that deinstitutionalization brought, we are faced with the need to understand the reactions and tolerance of the chronically mentally ill to the stresses of the community. And we must determine what has become of them without the state hospitals, and why. There is no evidence that nationwide very substantial numbers of the severely mentally ill are homeless at any given time (Arce et al. 1983; Baxter and Hopper in press; Lipton et al. 1983). Some are homeless continuously and some intermittently...We need to understand what characteristics of society and the mentally ill themselves have interacted to produce such an unforeseen and grave problem as homelessness. Without that understanding, we will not be able to conceptualize and then implement what needs to be done to resolve the problems of homelessness.
With the advantage of hindsight, we can see that the era of deinstitutionalization was ushered in with much naivetŽ and many simplistic notions about what would become of the chronically and severely mentally ill. The importance of psychoactive medication and a stable source of financial support was perceived, but the importance of developing such fundamental resources as supportive living arrangements was often not clearly seen, or at least not implemented. "Community treatment" was much discussed, but there was no clear idea as to what it should consist of, and the resistance of community mental health centers to providing services to the chronically mentally ill was not anticipated. Nor was it foreseen how reluctant many states would be to allocate funds for community-based services.
It had been observed that persons who spend long periods in hospitals develop what has come to be known as institutionalism--a syndrome characterized by lack of initiative, apathy, withdrawal, submissiveness to authority, and excessive dependence on the institution (Wing and Brown 1970). It had also been observed, however, that this syndrome may not be entirely the outcome of living in dehumanizing institutions; at least in part, it may be characteristic of the schizophrenic process itself (Johnstone et al. 1981). Many patients who are liable to institutionalism and vulnerable to external stimulation may develop dependence on any other way of life outside hospitals that provides minimal social stimulation and allows them to be socially inactive (Brown et al. 1966). These aspects of institutionalism were often not recognized or were overlooked in the early enthusiasm about deinstitutionalization.
In the midst of very valid concerns about the shortcomings and anti-therapeutic aspects of state hospitals, it was not appreciated that the state hospitals fulfilled some very crucial functions for the chronically and severely mentally ill. The term "asylum" was in many ways an appropriate one, for these imperfect institutions did provide asylum and sanctuary from the pressure of the world with which, in varying degrees, most of these patients were unable to cope (Lamb and Peele in press). Further, these institutions provided such services as medical care, patient monitoring, respite for the patient's family, and a social network for the patient as well as food and shelter and needed support and structure (Bachrach 1984).
Fernandez (1983), working in Dublin, recognizes these needs that used to be met, though not well, by state hospitals. He warns about the tendency to "equate the concept of homelessness exclusively with the lack of a permanent roof over one's head. This deflects attention from what is believed to be the essential deficit of homelessness, namely, the absence of a stable base of caring or supportive individuals whose concern and support help buffer the homeless against the vicissitudes of life. In this context, it is felt that the absence of such a base, or the inability to establish or to approximate such a base, is the essential deficit of patients with 'no-fixed-abode'."...
In the state hospitals what treatment and services that did exist were in one place and under one administration. In the community the situation is very different. Services and treatment are under various administrative jurisdictions and in various locations. Even the mentally healthy have difficulty dealing with a number of bureaucracies, both governmental and private, and getting their needs met. Further, patients can easily get lost in the community as compared to a hospital, where they may have been neglected but at least their whereabouts were known. It is these problems that have led to the recognition of the importance of care management. It is probable that many of the homeless mentally ill would not be on the streets if they were on the caseload of a professional or paraprofessional trained to deal with the problems of the chronically mentally ill, monitor them (with considerable persistence when necessary), and facilitate their receiving services.
In my experience (Lamb 1981) and that of others (Baxter and Hopper 1982), the survival of long-term patients, let alone their rehabilitation, begins with an appropriately supportive and structured living arrangement. Other treatment and rehabilitation are of little avail until patients feel secure and are stabilized in their living situation. Deinstitutionalization means granting asylum in the community to a large marginal population, many of whom can cope to only a limited extent with the ordinary demands of life, have strong dependency needs, and are unable to live independently.
Moreover, that some patients might need to reside in a long-term, locked, intensively supervised community facility was a foreign thought to most who advocated return to the community in the early years of emptying the state hospitals. "Patients who need a secure environment can remain in the state hospital" was the rationale. But in those early years most people seemed to think that such patients were few, and that community treatment and modern psychoactive medications would take care of most problems. More people are now recognizing that a number of severely disabled patients present major problems in management, and can survive and have their basic needs met outside of state hospitals only if they have sufficiently structured community facility or other mechanism that provides support and controls (Lamb 1980b). Some of the homeless appear to be in this group. A function of the old state hospitals often given too little weight is that of providing structure. Without this structure, many of the chronically mentally ill feel lost and cast adrift in the community--however much they may deny it.
There is currently much emphasis on providing emergency shelter to the homeless, and certainly this must be done. But it is important to put the "shelter approach" into perspective; it is a necessary stopgap, symptomatic measure, but does not address the basic causes of homelessness. Too much emphasis on shelters can only delay our coming to grips with the underlying problems that result in homelessness. We must keep these problems in mind even as we sharpen our techniques for working with mentally ill persons who are already homeless.
Most mental health professionals are disinclined to treat "street people" or "transients" (Larew 1980). Moreover, in the case of many of the homeless, we are working with persons whose lack of trust and desire for autonomy cause them to not give us their real names, to refuse our services, and to move along because of their fear of closeness, of losing their autonomy, or of acquiring a mentally ill identity. Providing food and shelter with no strings attached, especially in a facility that has a close involvement with mental health professionals, a clear conception of the needs of the mentally ill, and the ready availability of other services, can be an opening wedge that ultimately will give us the opportunity to treat a few of this population.
At the same time we have learned that we must beware of simple solutions and recognize that this shelter approach is not a definitive solution to the basic problems of the homeless mentally ill. It does not substitute for the array of measures that will be effective in both significantly reducing and preventing homelessness: a full range of residential placements, aggressive case management, changes in the legal system that will facilitate involuntary treatment...a stable source of income for each patient, and access to acute hospitalization and other vitally needed community services.
Still another problem with the shelter approach is that many of the homeless mentally ill will accept shelter but nothing more, and they eventually return to a wretched and dangerous life on the streets. A case example will illustrate.
*A 28-year-old man was brought to a California state hospital with a diagnosis of acute paranoid schizophrenia. He had been living under a freeway overpass for the past six weeks. There was no prior record of his hospitalization in the state. After a month in the hospital he had gone into partial remission and was transferred to a community residential program. There he was assigned to a skilled, low-key, sensitive clinician. Over a period of several weeks he gradually improved and returned to what was probably his normal state of being guarded and suspicious but not overtly psychotic.
*Though he isolated himself much of the time, he appeared quite comfortable with the program and with the staff and indicated that he would, if allowed, stay indefinitely. He denied possessing a birth certificate, baptismal certificate, driver's license, or any other proof of identity. He steadfastly refused to give the whereabouts of his family or reveal his place of birth or anything else about his identity, even though he realized such information was necessary to qualify him for any type of financial or housing assistance. Clearly his autonomy was precious to him. And in an unguarded moment he said, "I couldn't bear to have my family know what a failure I have been." At the end of three months, the maximum length of stay allowed by the community program's contract, he had to be discharged to a mission.
What was not foreseen in the midst of the early optimism about returning the mentally ill to the community and restoring and rehabilitating them so they could take their places in the mainstream of society was what was actually to befall them. Certainly it was not anticipated that criminalization and homelessness would be the lot for many. But first let us briefly look at how deinstitutionalization came about.
