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A room of one’s own
Budget cuts are squeezing residential services for the homeless mentally ill. With nowhere else to go, they may soon return to a street corner near you.
BY KRISTEN LOMBARDI


YOU SEE THEM every day. You see them wandering down the street, looking disheveled, mumbling to no one in particular. You see people like Keith W., 36, a homeless man from Revere with bipolar disorder who's battled post-traumatic-stress disorder ever since he witnessed his father shoot his mother to death in 1981. You see people like James S., 39, a homeless man from Woburn who, as a diagnosed schizophrenic, struggles to tame "the voices" and to "decipher fantasy from reality." And you see people like Steven S., 46, a man born and raised in West Roxbury, who suffers from depression and other mental impairments stemming from chronic child abuse and neglect.

The people you see are the homeless mentally ill in Massachusetts. And like Keith, James, and Steven, they spend their days largely in the shadows, on the fringes of mainstream American society. They bounce in and out of psychiatric hospitals — the result of suicide attempts or psychotic meltdowns. They often nurse drug and alcohol addictions. They spend their time shuffling from mental-health clinics to odd jobs to homeless shelters. Or they simply pound the pavement, "stemming," or panhandling, for a buck. More often than not, they do not relish life on the streets. Rather, they yearn to find a permanent home. To have their own bed, their own shower. To feel as though they’re part of this world. To feel as though, as Steven solemnly puts it, "I’ll finally have a chance at a good life."

That hope isn’t out of the realm of possibility. Indeed, mental-health experts, including officials at the Massachusetts Department of Mental Health (DMH), consider the first line of treatment for homeless adults suffering from mental illness to be safe, appropriate housing — and they don’t mean the average shelter. Emergency shelters can become a living nightmare for the homeless mentally ill. They’re crowded, chaotic, and offer no privacy — conditions that can cause mental-health problems to spiral out of control. The homeless mentally ill do far better in places like one of the six Boston-area homeless shelters for the mentally ill, such as Bay View Inn, in Quincy, where Keith, James, and Steven now reside. There, at least, they can enjoy a quiet, structured — if temporary — environment, with 24-hour care. Still, it’s not the same as DMH housing. A permanent residence would "get me back on my feet," says James. He adds, "I just want to be back to normal again."

BUT AS THE STATE’S budget problems have ballooned, DMH housing for the homeless mentally ill has shrunk. According to statistics published in November 2002, the most recent available, approximately 3400 mentally ill people across Massachusetts remain eligible for DMH residential services, but have yet to receive them. Many of them are homeless, living in shelters like the Bay View Inn, or languishing in psychiatric hospitals, because the DMH cannot find openings for them in group homes or staffed apartments.

Not surprisingly, recent budget cuts have exacerbated this backlog in housing services for mentally ill adults. Last year, during the fiscal year (FY) 2003 budget debate, the legislature wiped out just over $1 million from a $3 million program that offers rental assistance for DMH clients in need of housing — a move that resulted in the loss of 326 beds. This year, things seem even worse. First, in their attempts to balance the FY ’04 budget, legislators slashed $2.8 million from a line item for community adult mental-health services, which funds the department’s 7000 residential beds, among other programs. Secondly, for the first time ever, legislators chopped $1.5 million from a $22 million DMH program known as the "statewide homeless initiative." The initiative pays specifically for residential and support services for the homeless mentally ill. The unprecedented blow — a whopping 6.8 percent cut — puts as many as 120 spots slated for the homeless at risk. As Mary Ellen Holmes, of the Massachusetts Housing and Shelter Alliance (MHSA), explains, "This budget cut further threatens the enormous mismatch between [housing] demand and resources."

But in this era of fiscal austerity — when the definition of core services gets more and more narrow with each crunch of the numbers — state budget makers will have to come to grips with the homeless mentally ill sooner or later. After all, their numbers are significant — and climbing. According to the MHSA, at least 20 percent of adults who’ve become part of the soaring rise in homelessness this past year suffer from mental illness. The DMH estimates that 2000 homeless Bay Staters have severe mental-health problems. Of those, 1200 live in and around Boston. These men and women belie the conventional wisdom, which dictates that disadvantaged people can pick themselves up by their bootstraps and get back on track. Unlike other homeless, the mentally ill may hear uncontrollable voices. Or suffer overwhelming physical depression. Or experience paralyzing anxiety. They can sometimes manage their illnesses and lead productive lives — but not while slumbering on park benches. In the words of DMH community-services director Walter Jabzanka, who oversees the department’s homeless initiative, "These folks have not become homeless because of their own failings, their own insidious and irresponsible ways. That is a myth."

FOR THE HOMELESS mentally ill, housing has long seemed hard to come by. Lengthy delays between the time people first land on the DMH waiting list for residential services and they actually receive these services have been the norm for years now. Take, for instance, the plight of residents at the Fenwood Inn, a shelter operated by the DMH and located at the Massachusetts Mental Health Center, in Boston. The Fenwood, like six other shelters in and around the city, including the Bay View Inn, is supposed to be a brief, transitional place for homeless people who suffer from mental illness and who need housing. In recent years, however, it has begun to serve as a de facto home. Back in May 2001 — just as the state’s fiscal crisis was setting in — 11 of Fenwood’s 50 residents had stayed there an entire year while waiting for DMH residential services. Three of them had been there for more than two years. Today, not much has changed. As of July, 49 people are sleeping in the shelter’s 50 beds; 33 percent of them arrived in 2002, another 4.5 percent in 2001.

This backlog affects more than just the shelters. Over the past two years, a steady stream of troubled adults has entered psychiatric hospitals across the state — only to wind up stuck there, in limbo. To date, the DMH estimates that 200 people have become virtual prisoners in hospital wards because it has yet to find them open beds in group homes or staffed apartments. All 200 are homeless, with nowhere to go except the streets. All 200 remain in 24-hour locked units even though they could be discharged. All 200 must wait for safe, appropriate housing. For some, the delay amounts to weeks. For others, it’s months.

The gridlock has grown so bad that advocates have even resorted to legal action. In November 2001, lawyers at two watchdog groups for the mentally ill in Massachusetts — the Center for Public Representation (CPR) and the Mental Health Legal Advisors Committee — sent a demand letter on behalf of those stuck in hospitals to the DMH. In it, they threatened to sue the state for what they allege are civil-rights violations. They point to a 1999 United States Supreme Court decision that found that the Americans with Disabilities Act requires states to care for mentally disabled people in the least-restrictive settings. The lengthy wait for DMH housing, explains Robert Fleischner, a CPR lawyer who has worked on the case, "is a clear violation of the act."

The letter prompted the DMH to try to address its woefully insufficient residential services. Last April, the department closed Medfield State Hospital, which housed 135 mentally ill patients. As part of the closure, it scraped together enough money to convert several employee buildings on the campus into residential facilities — thus allowing 67 or so Medfield patients who were "discharge ready" to move into them. It’s also created staffing teams known as Programs for Assertive Community Treatment, or PACTs, which aim to keep formerly homeless people in their homes by offering intense, coordinated support services. The DMH’s action on these fronts helped assuage the advocacy groups, which have yet to file a lawsuit. Says Fleischner, "It was enough to satisfy our concerns — at least for the time being."

But the state’s ever-tightening budget crunch has arrested the momentum DMH officials had gained toward housing the homeless mentally ill. Since the start of the fiscal crisis in 2001, the department has absorbed a total of $38 million in spending reductions overall. Each year, as money woes have worsened, "Our ability to move people in the housing line-up has stopped," says former DMH commissioner Marylou Sudders, who left office last January to head the Massachusetts Society for the Prevention of Cruelty to Children. With the exception of housing associated with the Medfield Hospital closure, the DMH hasn’t been able to increase the numbers of residential beds. Consequently, it hasn’t been able to decrease the numbers of those waiting for housing. Adds Sudders, "We have seen absolutely no movement." (Elizabeth Childs, the current head of the DMH, was not available for interviews; she has been in office only since July 1.)

By all accounts, despite incredible pressure to cut its budget, the DMH has done all it can to protect residential beds thus far. Rather than force people out onto the streets — and thus add to the ranks of homeless mentally ill — the department has absorbed its budgetary blows in other ways. There are, for example, the 764 administrative positions that it has eliminated in the past two fiscal years. There are the 1800 mentally ill adults who have lost their outpatient treatment services. And there are the 2742 acute-care beds that outpatient psychiatric clinics had once set aside for the "free care" of poor, uninsured patients, all of which have disappeared.

By contrast, the DMH has not reduced funding for any of its residential programs. It has not cut any of its 7000 residential beds at group homes or staffed apartments — 1400 of which are designated specifically for the homeless mentally ill. Neither has it slashed any of the 165 beds at the six area homeless shelters for the mentally ill, including the Fenwood and Bay View Inns.

Such differences have become evident on the frontlines. The Chelsea-based North Suffolk Mental Health Center operates 72 outpatient clinics and residential programs in and around Boston. Currently, it’s grappling with what Bruce Bird, its chief executive officer, describes as "significant financial losses" in DMH funding for uninsured mentally ill patients. Last year, it received $200,000 from the department to cover the costs of providing free care to this population. This year, though, it has gotten only $50,000. The loss, Bird says, has left directors contemplating whether to shut down four of the center’s outpatient clinics in Greater Boston. On the residential front, however, all remains intact at North Suffolk. The center has not had to face even one reduction in its 810-bed housing programs. As Bird tells it, the DMH "has been courageous and effective in trying to preserve this system."

Indeed. Even when legislators slashed the $1.1 million in rental subsidies for DMH clients last year, administrators managed to mitigate the damage. According to Jabzanka, who also oversees residential programs, the cut dealt a "huge" blow to a skeletal program — roughly 30 percent of its $3.1 million budget. He and his colleagues faced the prospect of stripping away existing rental assistance for 165 mentally ill men and women — the vast majority of whom would likely have ended up homeless again. To avoid this, the DMH secured federally funded subsidies for all its clients. No one had to be displaced. Says Jabzanka, "It has been a priority of ours to hold residential beds harmless."

 

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Issue Date: August 1 - August 7, 2003
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