Living on Local Streets, Unhoused and Unstable

The loneliness and desperation of the homeless affect us all. However we rationalize their plight, the hard fact is that 30% of the homeless recently surveyed in California are severely mentally disabled, suffering from chronic or recurrent illnesses such as schizophrenia, major depression or manic depressive disorder. Because of illness, they have difficulty holding jobs or even performing simple tasks such as buying a bus ticket or making a medical appointment.

California is one of the first states to address the special needs of the homeless mentally disabled. The California Mental Health Services Act of 1985 allocated $20 million annually to the state’s 58 counties to support a wide range of services, from food and shelter to mental health services and vocational skill development. The program is unique, actively seeking out the mentally disabled on the street or in shelters and encouraging agencies to provide services and treatment tailored to each individual.

The California Department of Mental Health this year asked the RAND Corp. to assess how well this innovative program was meeting the needs of its target population. Our conclusion: The program is clearly a step in the right direction, but it needs both more resources and more effective ways to use existing funds.

We conducted detailed surveys in three California counties (Alameda, Orange and Yolo), scouring alleys, riverbeds and abandoned buildings at night to count the homeless and interview 315 of them. We also talked to more than 200 program staff members in 17 counties. From these efforts emerged a troubling picture of substantial need and of resources that can’t be stretched to meet the demand. Our survey of severely mentally disabled homeless shows that:

-- Almost half reported no contact of any kind with county service workers, despite efforts to reach them.

-- One in three is not getting enough to eat every day.

-- More than half have no one to help them obtain services.

-- Only a small fraction are getting benefits for which they are probably eligible: About one in eight receives Supplemental Security Income; one in four collects state welfare.

-- Only one in five visited a clinic for help with mental health or drug or alcohol problems in the past six months.

The gap between needs and services is particularly acute for some groups. Those who are very ill or who have been homeless a long time often refuse everything but food and occasional shelter. This vulnerable group often needs hospitalization as well as continuing mental health treatment; there is remarkable consensus among program staff that easing the legal requirements for involuntary hospitalization is desirable. But unless this change is accompanied by more beds and access to outpatient facilities, committing the hard-to-reach will disrupt rather than benefit them. A brief stay in the hospital won’t make them better, and while they are away, they may lose their few possessions or a sheltered sleeping place.

The majority of the severely mentally disabled--more than two-thirds--are also drug or alcohol abusers. One of the most damaging weaknesses of the current program is that these “dual-diagnosed” homeless fall through the crack between the mental health and substance abuse treatment systems. Most mental health agencies won’t accept someone for treatment who is currently drunk or high, and most drug and alcohol programs won’t accept those with mental disorders. This Catch-22 arrangement means that many homeless who desperately need assistance but are poorly equipped to seek it are excluded from programs and told to find help elsewhere.

Because of the chronic nature of their illnesses, most severely mentally disabled people will require treatment and services for life. But the current county programs can’t provide the necessary continuity of care for a variety of reasons.

County mental health services lack the capacity to accept many new patients from the homeless programs. The counties also lack appropriate low-income housing alternatives. Often the homeless face a stark choice between living entirely alone, which many cannot manage or afford, and group residential facilities such as board and care houses with very restrictive rules.

Entitlement benefits such as General Assistance or Supplemental Security Income can provide a source of income and some financial stability. But many of the homeless mentally disabled cannot get and maintain eligibility for these programs without someone to help them negotiate a process that is both complex and time-consuming--the welfare form in one county is 32 pages long.

Finally, those with chronic mental disorders need to be linked to an appropriate support system that can assist in time of crisis. But the counties are hampered in following up clients, because this population is mobile and unstable, and because case managers are often required to maintain excessive caseloads--as many as 80 to 100.

Closing these gaps between needs and services will require more money--at least as much as double the current $20 million annual budget. To help determine how much is really needed, we provided the state with as accurate a count as possible of the homeless in three California counties: Alameda, about 1,000 on a given night and about 2,800 over a year; Orange, about 1,000 on a given night and about 4,400 over a year; Yolo, about 100 on a given night and about 200 a year. Although these estimates are almost certainly low, they suggest, for instance, that the number of available shelter beds in the three counties we surveyed falls short of the need by 50% to 70%.

Yet there are at least five things that the state and counties can do immediately--with relatively modest addition or reallocation of funds--to make existing programs more effective:

--Bring physical-health clinics into the referral network. Agency-to-agency referral is the most effective way to link the homeless to needed services, but physical-health clinics aren’t part of the referral network despite the fact that more than half of those we interviewed had visited such a clinic in the past six months.

-- Provide assistance with the entitlement process. Several of the counties experimented with ways to help the mentally disabled homeless obtain entitlement benefits--for example, educating agency staff to identify and work with the mentally disabled. The results were good, and the experiments could be expanded.

-- Improve case management. This is a tough problem because there are privacy issues involved, but computer technology has the potential to help case managers monitor the status of those clients “at risk” of homelessness. For example, a simple marker in an individual’s welfare or SSI file could indicate that he or she was mentally disabled and had a history of homelessness. If that person failed to appear for recertification, case managers in the homeless program could be automatically notified so that they might intervene to prevent the loss of benefits--a loss that might cause another episode of homelessness.

-- Provide help for the homeless whose mental disorders are complicated by drug and alcohol abuse. Some counties have developed special task forces to bring mental health and substance-abuse counselors together to find workable solutions for those with dual diagnoses. But in spite of these attempts, the barriers remain fundamental ones: Approaches to treatment differ; professionals in one area aren’t familiar with problems in the other.

-- Continue to educate the public about the special problems and nature of mental illness. The counties’ ability to serve the homeless mentally disabled continues to be hampered by strong community or neighborhood feelings of “yes, but not in my back yard.” The agony and human waste of homelessness and mental illness aren’t a passing problem. No silver bullets here. Only commitment of resources, compassion and imagination can help.