E-Mail This Article to a Friend A room of one’s own (continued) BY KRISTEN LOMBARDI

OF COURSE, the department can take only so much. After three years of persistent whacks from the budget ax, the DMH has sustained cuts slicing, in the words of one advocate, "deep into the bone." Sooner or later, the agency will have no choice but to slash its residential programs. The latest round of cuts, in fact, has already begun to chip away at the existing safety net for the homeless mentally ill. After all, money appropriated under the DMH homeless initiative goes directly toward building beds for homeless clients, as well as providing them with support services. At the same time, the rental-subsidy program helps move people living in group homes into their own apartments — which, in turn, opens units for the homeless in shelters and hospitals. So, if the safety net seemed fragile before, says Sudders, "It’s shredded, with huge holes today." Eventually, she adds, "people are going to fall through."

Some people already have. According to Jabzanka, since the rental-subsidy program lost money last fiscal year, the DMH has experienced a "net loss" in the numbers of people who can receive assistance in the first place. In 2002, it had subsidy slots for 900 mentally ill adults. This year, it’s been able to dole out aid for only 574. "This," he explains, "has cut into our ability to house that many more people."

Jabzanka and his fellow DMH administrators are now wrestling with a similar scenario as they figure out how to accommodate the $1.5 million cut to the homeless initiative. Although he insists that the department is "working hard" not to displace any of its clients, he admits that the pressure to do so exists. As it stands, the DMH is weighing its options — it may, for instance, decline to fill residential units that become available, as opposed to forcing people currently housed there onto the streets. In any event, the unprecedented cut will translate into a sudden loss of beds for homeless and mentally ill adults. The worst-case scenario? The DMH, Jabzanka says, may have to close up to 120 beds. "The last thing we want is to toss people on the streets," he says. But he recognizes that such an outcome is "a real possibility."

His words probably don’t offer much consolation to service providers, who are on edge as they wait for the DMH to gauge the impact of the latest cuts. At the Boston-based Pine Street Inn — which assisted 1400 homeless adults suffering from mental illness in 2002 — program directors fear what may happen to the 68 people who now live in the Inn’s six residences for the homeless mentally ill. When the DMH rental subsidies took a hit, Pine Street lost $2.4 million in funding for its Paul Sullivan Housing Trust, which offers housing and support services to the homeless mentally ill. Lyndia Downie, who heads up Pine Street Inn, explains that she and her colleagues had to scale back on housing staff who help residents get back on their feet by assisting them with job searches, shopping, budgeting, and so on. Another spending reduction could have devastating consequences for the Inn’s current tenants. "If we cannot keep up the support," Downie says, "we will be hard-pressed to keep people housed." Moreover, she worries about what a looming cut might mean for the Inn’s future housing projects. Right now, the agency has secured $1.49 million to construct two more residences for the homeless mentally ill — in Dorchester and Roxbury. Both homes would supply much-needed permanent housing. Yet without homeless-initiative funding, in Downie’s words, "it could be the make-or-break point for these projects. It’s all up in the air."

Even those who offer residential mental-health services not specifically slated for the homeless worry about a precarious future. While their programs have remained unscathed during the fiscal crisis, they are still hurting. Providers have not received increases in their DMH-funded contracts in more than a decade. So they haven’t rehabilitated their group homes and apartments. They haven’t given their employees a raise. They haven’t boosted support services for clients. The system, in short, is strained. As Bird, of North Suffolk, explains, "We’ve lost tremendous ground anyway, and these [budget] cuts just compound the situation." Among the provider community, some DMH vendors already teeter on the brink of financial collapse; the smallest decline in resources could put them out of business. So how the DMH allocates the latest $2.8 million cut in adult community services, which funds most residential programs, could result in a further loss of residential beds.

The DMH, for its part, does not downplay the severity of the situation. Jabzanka suggests that the $2.8 million spending reduction in community mental-health services for adults will likely affect other programs first — like, say, psychiatric day treatment and DMH drop-in centers. But he acknowledges that "some money" will have to come out of funding for residential programs. And the brunt of such a move is sure to have a negative effect on the formerly homeless people who live in subsidized housing and who receive support services at home. People, Jabzanka says, "who are in the community and who very much need these services."

People, for example, like John Prisinzano, a 54-year-old Roxbury resident who suffers from psychosis and depression. A gangly, bespectacled man, Prisinzano lives in a federally subsidized apartment, where he enjoys a spacious living room, a countertop kitchenette, and enough closet space to store his bicycle. He moved into his School Street residence in 1998, after a decade of bouncing in and out of hospitals and shelters. Now, it seems, he may be in jeopardy of losing his home. That’s because the basic mental-health services that he currently receives, which are funded by DMH and provided by Vinfen, a Cambridge-based human-services agency, could be threatened by the latest cut to community-mental-health services. And as mental-health experts tell it, even the slightest decline in services is enough to destabilize mentally ill adults and cause them to lose their homes.

News of recent budget cuts to DMH housing and support services has left Prisinzano with mixed emotions. On the one hand, he fears the prospect of getting less help at home. Especially since he doubts that he could survive "on the outside," without the 24-hour care he now receives. When he slips into a bout of depression, he can hide in his apartment and tune the world out. If the episode becomes too overwhelming — and a typical one lasts days — he can turn to the mental-health counselors, who make sure his basic needs are met.

On the other hand, the DMH cuts anger him. He knows that if state budget makers keep slicing away at residential and support programs, he could very well end up homeless again — a thought that he finds "devastating." Since he’s lived in the School Street building, about a half-dozen of his friends suffering from mental illness and wandering the streets have died while waiting for DMH housing. They’ve perished, in his words, "from the ills of homelessness" — frostbite, addiction, and street violence. These are realities for formerly homeless people, like Prisinzano, who may be at risk because of the budget cuts. As he confides, "I feel state [budget makers] are saying, ‘To hell with the poor, the mentally ill, and the homeless.’ It irritates me."

TO BE SURE, housing the homeless mentally ill — and keeping them housed — is the right thing to do. It’s also the smart thing to do. Since 1992, when the DMH established its homeless initiative, the program has enjoyed great success in getting more bang for its buck. DMH officials have obtained nearly $90 million in federal funding for the program, which has paid for actual housing construction. As a result, the department has built as many as 1400 permanent-housing units for the homeless mentally ill. Last year, DMH officials used the $22 million appropriated for its initiative to place and care for 2400 people in those units.

And once the homeless mentally ill secure housing, they tend to stay there — which is far less expensive for society as a whole. They’re no longer left to fend for themselves on the streets. They’re no longer as likely to clog up emergency rooms. They’re no longer as likely to self-medicate with drugs and alcohol. Jabzanka points to a May 2001 study indicating just how cost effective it is to provide housing for the homeless mentally ill. The study looked at 4679 homeless people with severe mental illness, some of whom moved into housing and some of whom didn’t. The study found those mentally ill adults in housing made far less use of shelters and hospitals. It cost an average of $16,282 per person per year in human services to address their needs — but that pales in comparison to those living on the streets. The second group racked up the hefty price tag of $40,449 per person per year. Concludes Jabzanka, "Unless the homeless mentally ill are served, they cost society far more money in the long run."

Today, as mental-health advocates wait for the latest budget cuts to take effect, they’re gearing up for just such a costly scenario. Clearly, the reductions will make the wait for DMH residential services longer. And this can lead only to more homelessness. According to Holmes, the director of the Boston-based MHSA, homeless shelters statewide have already seen an increase in mentally ill adults walking through their doors. Now, she says, "We’re facing threats to the back door of services." And without them, she notes, "we will only boost homelessness."

Advocates also predict an inevitable rise in the number of homeless stuck in hospital wards. The more mentally ill people living on the street, the more who will find themselves in risky situations — open to robbery, assault, and disease. Hence, the more they end up in already-strained emergency rooms. As the former DMH commissioner, Sudders worries that the latest cuts will serve to replicate the human logjam long evident in the system for children’s mental-health care. "If we’re not careful," she says, "we will create a crisis on the adult side just like the one" involving children stuck in psychiatric wards.

Even DMH officials agree. Because the department does not have the money to create more housing, Jabzanka says, "any one of the system’s slots can jam up and stop the whole flow" of the system. He adds, "We’re not going to be able to serve people like we used to."

For homeless people like Keith W. and company, this probably seems like more of what they’ve long become used to. More of the wait, the instability, the dream. Though they occasionally grumble about the lengthy delay for DMH residential services — as Keith himself puts it, "I’m not a very patient person" — they’ve come to realize that they don’t have much of a choice. They each survive on roughly $600 per month in disability benefits. Even if they didn’t need support staff and services, they couldn’t afford their own apartments in today’s housing market. It’s either wait or venture back onto the streets, where they’re at the mercy of the elements and the chaos.

So for now, all they can do is hope. Hope they don’t lose their shelter beds. Hope the disorder in their lives doesn’t trigger a flare-up. Hope that one day, they can have a place to call their own. Steven S. sums up the sentiment: "I hope I’ll finally get what I want in life, my own bed, my dignity back." He sighs and then adds, "I just hope things work out for me in the best possible way."