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EDITORIAL
OP-ED; We can't legislate away homelessness
Thomas M. Keane Jr.

01/29/2003
Boston Herald
All Editions
029
(Copyright 2003)

Bitter cold took one life last week: Robert Gurney, a 72-year- old homeless man who refused to enter a shelter. The solution seems obvious: Give police and health workers the power to pull people off the streets, putting them into what is called protective custody.

Many critics say measures such as these are long overdue, part of a much larger issue. Homelessness, they say, is a direct consequence of a failed social experiment: Deinstitutionalization.

Up through the 1950s, mentally ill people were housed in insane asylums. Often, the mere fact of mental illness was enough to justify a commitment. By the end of the 1950s, 550,000 were in institutions - off the streets and, for the most part, out of mind.

By virtually every account, conditions in those institutions were appalling. Inmates lived in filth, they were physically and sexually abused, and they were largely denied any opportunity of returning to normal society.

That changed in the 1960s. The impetus came from President John Kennedy, whose sister Rosemary was both mentally retarded and mentally ill. Exposes, such as Ken Kesey's 1962 book "One Flew Over the Cuckoo's Nest," brought public attention to the bleak and cruel treatment of the mentally ill. Moreover, psychiatry was changing: Wonder drugs promised miracle cures.

These events combined to create a movement that eventually caught on throughout the country. Called "deinstitutionalization," laws were changed to make it vastly more difficult to commit anyone to an asylum. The mentally ill were discharged, with the theory being that they would be placed in community settings where they would receive appropriate treatment, including drugs, and reintegrate into society.

If the goal of deinstitutionalization was to get the mentally ill out of asylums, then it succeeded admirably. Kennedy had spoken of reducing the number in custody by 50 percent; in fact, there are now fewer than 70,000 in mental hospitals.

But if the goal has been to get better care for the mentally ill, the record is much more dismal.

Good intentions aside, perhaps 40 percent of the mentally ill get no care at all, according to the National Advisory Mental Health Council. Where do they end up? Steven Raphael of the University of California estimates that somewhere between 48,000 to 140,000 of the mentally ill simply ended up in prison (leading some to say that deinstitutionalization is really just trans-institutionalization).

Others ended up on the street: One-third of the homeless are mentally ill, according to Daniel Graybill of Illinois State University. Deinstitutionalization, these critics argue, is in large part responsible for the rise in homelessness over the last several decades. Solving the problem means admitting that community-based care has been a failure. Make it easier to commit the mentally ill. Get them off the streets and into treatment.

Not so fast.

It certainly is true that it is hard to get someone civilly committed. The standard now is that a person must be an imminent danger to himself or herself or to others. Merely being foolish - staying out in cold weather - is not enough (if it were, we would be committing mountain climbers).

Yet few of those working with the homeless and mentally ill are clamoring for a change in civil commitment laws. The issue, they argue, is not compelling someone to get treatment. Rather, it is providing the resources so that treatment is available. For example, the National Institute of Mental Health had originally projected 2,000 community health centers would be needed to handle those who were discharged; less than a quarter of those were actually built.

Moreover, advocates fear that changing civil commitment laws would be counterproductive, undoing a lot of good that has recently been accomplished.

Take Boston. The city figures that it has 6,210 homeless. The large majority of those are not mentally ill. Many, in fact, are women with children and their issues seem related to the lack of a spouse, a job and affordable housing.

And even of those who are mentally ill, only a small number - between 50 and 100 - refuse help from outreach workers. Moreover, as Eliza Greenberg, director of Boston's Emergency Shelter Commission, points out, only one person has died of exposure over the last four years.

And what would changing the law accomplish? Any effective treatment of mental illness ultimately requires the patient's cooperation. The 50 to 100 now on the streets would avoid being picked up, would try to escape confinement or would resist treatment. A change in the law might actually reduce the chances that those - and others - would participate in a cure.

True, the heart breaks on a harsh, freezing night. Decency might seem to demand that we pull the homeless off the streets, no matter what. But it's a quick fix that offers the illusion of compassion. Real compassion, it turns out, is a much harder thing.

Tom Keane can be reached at tomkeane@tomkeane.com.