Thinking About the Homeless

...The Urban Institute believes that as many as one in four have criminal records...

...Although the liberal argument makes intuitive sense, the problem of homelessness may well go deeper than anything wrought by the Reagan White House...

...At a time of widespread gentrification and tight-fisted federal housing policy, as many as one million units were destroyed in singleroomoccupancy hotels alone...

...At some point in the 1960s, federal funding made it cheaper to shunt patients into nursing homes, where they received only the poorest custodial care...

...Can we force nonviolent people to stay in a hospital against their will...

...Medications and involuntary hospitalization should be used as sparingly as possible...

...After more than a decade with the problem, we still have no idea how many homeless there are, where they come from, what is wrong with them, whether their number is growing—even whether some of them want help or not...

...An emerging consensus holds that at least one-third of the homeless suffer from serious mental illness...

...Today, the flow of money still encourages institutional warehousing...

...Isaac and Armat abhor all counterculturalism, and they often sound painfully shrill as they rail at the left-leaning lawyers who took the cause of patient liberation to court...

...The liberal advocates are not wrong to say that this population needs society's help, but it does no good to misrepresent the nature of their problems...

...Whether a third or half of the homeless, these are the people with the most easily identifiable problem, and there is little disputing why they are on the street...

...In fact, her own descriptions of mental patients completely undercut the claim that there is no such thing as madness, or that it has anything to teach the rest of us...

...One, by sociologist Rael Jean Isaac and editor Virginia Armat, comes out of the neoconservative camp...

...Where left and right differ is on the question of involuntary commitment...

...Crack, family violence, pervasive and senseless crime: these pathologies distort countless ghetto lives to one degree or other...

...Johnson is still quite taken with the libertarian ideals of the sixties: she believes deinstitutionalization was a good idea, just badly implemented...

...As many as 70 percent of these women, according to one Harvard study, have proved unable to hold jobs or form relationships with other adults...

...we understand implicitly that his parents have a responsibility to stop him...

...The American public responded with concern, even generosity...

...On this, Isaac, Armat, and Johnson agree: the psychiatrists are the villains of the piece...

...As one Szasz follower wrote in the early seventies: "Our use of the adjective 'sick' for such people shows only our own arrogance in believing the mainstream as we define it is `well.' " The folly of such ideas hardly seems to need comment today, though unfortunately neither of these books can quite leave it at that...

...She also saw patients discharged to homeless shelters or addresses that were empty lots...

...By definition, SPRING • 1991 • 251 The Homeless chronics do not get better...

...At least one-third to one-half abuse illegal drugs and alcohol...

...Yet, for all the appeal of the liberal view, conservatives argue persuasively for some skepticism...

...306 pp., $22.95...

...This does not mean, of course, that patients have no rights—and in providing care, we must make every effort to safeguard those rights...

...Among the most important—as propounded by R.D...

...Isaac, Armat and Johnson more or less agree on what's needed...

...Journalists tell of still more widespread personality disorders...

...Conservatives, keen to refute any symbolic indictment of the society, argue that there may be no more than 200,000...

...Isaac and Armat are right in their search for an alternative theory that would counterbalance rights-based thinking and justify compulsory care—in some instances, at least...

...Instead of arguing recklessly for homeless people's right to roam the streets, liberals ought to be thinking harder about what kind of care and treatment society owes them...

...Above all, we must develop and pay for the kind of nonrestrictive community care that we have been promising mental patients for thirty years...

...We have to find ways to help these people if we are to make any claim to being a humane society...

...Medically, they say, we must be realistic: there is such a thing as mental illness...

...Both show that the liberation ideologues and mental-health bar were pushing against an open door from the late fifties on...

...Most shrinks were thrilled to get out of the state hospitals, and once they were working in community clinics, they actually shunned psychotic patients who followed them there...

...The two books differ somewhat in exactly whom they blame for the failure of deinstitutionalization, but even here there is considerable overlap...

...As throughout her book, Johnson is admirably loyal to patients' interests and on target in her effort to shame the rest of us...

...A more humane argument 252 • DISSENT The Homeless would start from something like what communitarian political philosopher Michael Sandel calls the "obligation of mutual care...

...HUD says that 21 percent are victims of domestic violence...

...Laing, Michel Foucault, and Thomas Szaszwere the claims that there is no such thing as mental illness, that hospitals actually cause disorders, that all patients really need is to be liberated...

...That treatment of the chronic mentally ill will never yield dramatic results, and will grow more and more expensive, in no way gets us off the hook...

...They concentrate their fire on the arguments of the libertarian lawyers—claims about patients' rights to autonomy, to leave the hospital, to forgo treatment, and to stop taking helpful medication...

...Those who take the broader view argue that what we call homelessness is essentially an underclass problem...

...Johnson says absolutely not: she sees involuntary hospitalization as "incarceration" —punishment, not treatment, designed for society's convenience...

...That, perhaps, is why so much of the debate about homelessness has come to focus on the rather obscure issue of "deinstitutionalization" —the wholesale emptying of large state mental hospitals that began in the sixties and continued through the seventies...

...Isaac and Armat, whose politics predispose them to dislike deinstitutionalization and call for rehospitalizing the psychotic homeless, are ironically the most vivid on this point...

...Let us assume, then, that they are largely troubled people who would have difficulty functioning even in the best of times...

...Johnson is concerned above all with the way government funding skewed the process and still impinges on what little care chronics get...

...Their book paints a horrifying portrait of medieval-type wards filled beyond capacity with naked, screaming patients...

...In truth, the case for taking care of mental patients—and the rest of the homeless—is far too important to be left to conservatives...

...Philosophically, they quote tellingly from John Stuart Mill...

...Nor is it clear that many apply for welfare benefits...

...By now, most Americans are aware that the symbolism evoked by Hayes and others masks a more complicated reality...

...Johnson tells chillingly of these doctors' techniques: how they moved their offices without informing patients and made their waiting rooms so inhospitable that the very ill—who aren't good at being on time—simply found it too uncomfortable to bother with appointments...

...A widely used estimate by the Urban Institute suggests the figure of 600,000...

...Isaac and Armat have a different beef: they are irked by the rights-based logic that was used to justify emptying the hospitals...

...Not even Millian notions of liberty extended to children, the irrational, or the delirious: "Those who are still in a state to be taken care of by others," Mill wrote, "must be protected against their own actions as well as against external injury...

...Shelters and soup kitchens sprang up in the cities, the overwhelming majority paid for by churches and other private groups...

...quite apart from the schizophrenia and depression that qualify as "major mental illness," large numbers of homeless seem unable to deal with routine living...

...In theory—theory written into federal law in 1963—the old state hospitals were to be slowly replaced by smaller, more humane, and treatment-oriented "community mental health centers...

...This uncomfortable symbolism had a special power in the self-indulgent eighties...

...up roaming the streets, muttering to themselves, and foraging in trash cans...

...The problem is that even a history of violence is rarely enough to demonstrate that someone is dangerous...

...Parents often watch helplessly as their disturbed children stop taking medication: their delusions and anger soon come to the surface...

...They are the kinds of people who suffer most when poverty rises, and they cannot have prospered in the Reagan era...

...Unlike a few years ago, even the liberal Johnson can now acknowledge this...

...And most of the experimental treatment around the country involves the same components: some psychiatric supervision, the creation of an extended family unit (a halfway house or club or "pact") where patients can feel at home, training in "basic life skills" (from grooming to budgeting to eating in a restaurant), and, for most, some kind of work...

...Still, it is surely inaccurate—and misleading for policymakers —to argue that these people's plight is caused primarily by either a lack of money or a lack of housing...

...Things didn't work out that way, and many, if not most, of those patients ended * Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill, by Rael Jean Isaac and Virginia C. Armat...

...Indeed, it seemed to many, the misery of homelessness was the other side of the eighties: the inevitable underside of heartless, unregulated Reaganism...

...Two new books on deinstitutionalization reveal how far this debate has gone...

...Still, the parents cannot get them into a hospital until they are actually caught in a violent act...

...Bitter ideological disputes have developed around these questions...

...Conservative experts emphasize mental illness and pathology...

...Experts who believe this to be true divide further into two groups...

...Of course, she also blames the homeless problem on housing scarcity and welfare cutbacks...

...Left and right agree that the homeless are disproportionately male and minority...

...Community clinics concentrated by design on helping "the worried well" —middle-class people looking for counseling— and deinstitutionalized chronics simply fell through the cracks...

...436 pp., $24.95...

...Not only had psychiatrists lost faith in large institutions, most of them were bored and embarrassed treating chronic mental patients...

...Like blacks in the sixties and Okies before that, the homeless reminded us of the still yawning gap between our lives and our ideals...

...New York: Basic Books...

...and Out of Bedlam: The Truth About Deinstitutionalization, by Ann Braden Johnson...

...Can we force them to undergo electric shock treatment and even psychosurgery...

...Isaac, Armat, and Johnson agree that many chronic patients will now and then have to go back into the hospital...

...Often, of course, it is too late...

...She watched patients who were "openly hallucinating and bristling with hostility" leaving hospitals without anywhere to go...

...With their symptoms calmed by Thorazine and other drugs, patients were expected to live "in the community," where the habits of normal life and productive work would eventually restore them to something like sanity...

...The public is growing increasingly skeptical that we know how to help the homeless...

...Advocates for the homeless—generally liberals—assert that there are as many as two to three million homeless people...

...q SPRING • 1991 • 253...

...Here agreement ends, giving way to endless debate about precisely what proportion are families (onequarter or half), what proportion single men (45 to 80 percent), how many are substance abusers (one-third, one-half, and two-thirds are among the estimates) and how many are mentally ill (figures range from 15 to 95 percent...

...Both sides also agree that deinstitutionalization has been an utter failure...

...Conference of Mayors—suggest this sympathy may be waning...

...For him, the cause of homelessness is "dysfunctional behavior" — addiction, chronic joblessness, detachment from friends and family...

...Even more hotly contested than the numbers is the question: who are these people...

...This will not come cheap, nor will it be politically popular...

...What the mentally ill need from us is not that we grant them their rights but rather that we shoulder some responsibility...

...But most of the arguments they come up with—about the rights of patients' families and the danger to the social order—sound either forced or grudgingly self-protective...

...The civil libertarians who fought for deinstitutionalization should have noticed something wrong as early as the sixties when they found themselves allied with Governor Ronald Reagan, then determined to close all California mental hospitals in order to save money...

...They are mainly young adults, and those designated as families tend to be single mothers from the underclass...

...But as someone who was working in the mental health system at the time, she knows what passed for deinstitutionalization...

...Federal, state, and local governments contributed about a billion dollars for shelters...

...But recent signs—including a study released in December by the U.S...

...No serious person would assert a small child's right to walk out the front door into a cold winter night...

...New York City advocate for the homeless Robert Hayes stated the argument: "The homeless are indeed the most egregious symbol of a cruel economy, an unresponsive government, a festering value system...

...Whether their problems are caused by deinstitutionalization or by the pressures of underclass life, many hundreds of thousands may need extensive services over their entire lives...

...The conservatives' argument here is both medical and philosophical...

...Unemployment is rising—and is pervasive among the homeless— but it's far from clear that many homeless actually go out to look for work...

...And he sees this behavior as a product of what's happening in the ghetto: the drug culture, the breakdown of the black family, the way so many minority men now spend their youth in prison instead of high school...

...the other, by mental-health worker Ann Braden Johnson, rests on traditional liberal assumptions about homelessness and psychiatry...

...One survey, by clinicians from Johns Hopkins University, estimates that among those who are single 72 percent of the men and 95 percent of the women suffer from some kind of mental disorder (about half from phobias and other anxieties that don't classify as major illness...

...Isaac and Armat argue that mental patients lack the ability to make an informed choice— and insisting on their right to such choices is absurd and inhumane...

...We must learn to distinguish between the merely eccentric and the truly psychotic...

...The homeless are simply those who have been hit the hardest...

...In 1989 some 70 percent of those answering a Gallup poll said they wanted the government to step up its efforts...

...In 1988 the Department of Housing and Urban Development (HUD) counted 5,400 shelters nationwide...

...The homeless, whether mentally ill or just plain troubled, are less in need of lawyers than of lobbyists—people who can make the case that we need to help...

...Still, these books differ on what it is that bothers them about deinstitutionalization...

...In fact, even liberal advocates have trouble finding many homeless like that...

...The apt analogy is not a criminal— who does have certain rights to autonomy and due process—but an infant...

...And alternatives, like twenty-four-hour companions during crises, should be available...

...The other group of experts who trace homelessness to pathology sees it more narrowly as a mental-health issue, concerning themselves only with those who suffer from "serious mental illness...

...The two works differ on a wide range of issues, but even more fascinating is what they agree upon...

...Not all the homeless will need that much care, but—if the skeptics are right about their mental health—many will...

...There will be no definitive resolution of this quarrel until we have better evidence from the streets and shelters...

...often they even threaten violence...

...Hospital care must be top quality—no warehousing in dingy back wards...

...Some of these centers were meant to include residential care, but many were intended merely as outpatient clinics...

...New York: The Free Press...

...Can we force them to take medication they resent— even if it makes them feel better...

...To give the symbolic argument its full force, they should be ordinary middle- and working-class families—preferably white—reduced to poverty during the Reagan years...

...Professor Peter Salins of Hunter College is among those who make this argument, though he does not use the term "underclass...

...Those who blame the problem on SPRING • 1991 • 249 The Homeless Reaganism focus on the families, veterans, children, and formerly employed...

...There is little dispute that the Reagan era brought a shrinkage of welfare benefits and low-income housing...

...This is a less sexy political question than poverty or the 250 • DISSENT The Homeless underclass or government social policy...

...Both books heap blame on American psychiatry...

...Some researchers say that a third have spent time in psychiatric hospitals...

...Average yearly costs per patient rose from $720 in 1949 to $41,650 in 1984...

...Yet, as skeptical researchers point out, cities with tightening housing markets are not necessarily those with the biggest homeless problems...

...As the law stands today, patients can refuse care unless and until they are proved dangerous to themselves and others...

...Call them the lowest of the underclass, or those who have fallen out of it...

...She argues persuasively that the most important cause of deinstitutionalization was the states' unwillingness to pay for their big hospitals...

...Isaac and Armat say the civil liberties bar won for these essentially incompetent patients the right to ruin their own and their families' lives...

...For one thing, both concur that the old state mental hospitals were unspeakable places — huge, poorly run custodial warehouses where most patients were left to rot...

...Chronic mental illness is by nature a lifelong disease, and often there is no alternative to inpatient care...

...To the degree that they can make decisions for themselves, they should be free to do so...

...Dirt poor, out of work, without a safety net, the pitiful army of the "homeless" pricked the country's conscience...

...Yet, as one of the few clear causes of homelessness, it too has become a hotly contested issue...

...since 1987, Congress has authorized between $400 million and $1 billion a year to cover both this temporary housing and services like job training and drug counseling...

...Even those from the subgroups thought to be the sanest—the veterans and families (that is, single mothers)—often seem traumatized...

...Both note the role played by the countercultural ideas of the sixties...

...On this issue, then, the liberals were right—patients had to be rescued from those old-style loony bins—and Isaac and Armat are to be credited for their honesty in admitting so...