The holidays are about caring and compassion, but despite the seasonal spirit, there is still a segment of society left out in the cold: the mentally ill and homeless.  These are some of societies’ most disenfranchised and are easy to overlook.  They are the shabbily dressed hallucinating individuals who tote their worldly possessions in plastic bags and sleep on grates.  Without adequate treatment, many of the mentally ill wind up homeless or in jail.

According to the Treatment Advocacy Center between 150,000 to 200,000 homeless individuals suffer from bipolar disorder or schizophrenia.  In order to understand this problem, we need to identify not only who these street dwellers are, but how they got there.  Psychotic street dwellers have not always been a part of city landscapes, and in bygone decades, greater efforts were made to house and take care of these vulnerable individuals.

Much of the increase in mentally ill homeless occurred as a result of a well-intentioned if ill-advised social experiment known as deinstitutionalization.    Deinstitutionalization came on the coattails of the civil rights movement and sprang in part from the belief that everyone has a right to beat to their own drummer (no matter how psychotic or paranoid that drummer may be).  Mental hospitals were closed in mass and the severely mentally ill were returned to the community, too often lacking the resources they needed to survive on their own.

President Kennedy authorized the building of community mental health centers, which were designed to provide treatment to seriously mentally ill individuals while they remained “in the community.”  The idea was that mental health workers would do community outreach and coax the severely mentally ill into treatment voluntarily.  This idea is appealing, but not always practical.  How is the mental health worker to reach out to the severely paranoid psychotic individual?  How about: “I understand that the CIA has implanted a chip in your head, come to the local mental health center and we’ll try to change the channel.”

Another outgrowth of deinstitutionalization is a more narrow interpretation of   commitment statutes.  The predominant criteria for involuntary commitment today is dangerousness.  “You can be as manic or psychotic as you want to be without being forced into treatment, as long as you are not a danger to yourself or others,” explains Dr. Daniel Leggiadro PhD. of the Lancaster County Crisis Center in Lincoln, Nebraska. Leggiadro gives the example of an actively psychotic transient who was repeatedly jailed for sleeping where he was not supposed to sleep, specifically, in university stairwells.  Recognizing that the man was mentally ill, the jail took him to a psychiatric hospital for treatment.  The hospital was unable to keep him however, because while psychotic and unable to find a place to live, he was not an imminent danger.  Says Leggiadro “I’m not against civil liberties, but sometimes people cannot appreciate their civil liberties.”

Freedom from involuntary treatment has too often translated into the freedom to be a floridly psychotic homeless person periodically jailed for trespassing. This form of “freedom” is a mockery of the word.  What the deinstitutionalization movement has shown is that despite the progress that has been made, there is still a lot of nuttiness in mental health.

To reverse the havoc that deinstitutionalization has wreaked, policymakers should expand the commitment criteria from dangerous to include gravely impaired.  No one should have to deteriorate to the point of being a danger to themselves or others in order to receive help. 

Closed down state hospitals should be reopened and remodeled recognizing the fact that there are too few inpatient facilities available. Medications aren’t always taken and sometimes do not work, for that reason a need for inpatient facilities will continue to exist despite pharmaceutical breakthroughs.  And some individuals are simply too sick for independent living to ever be a viable option.

If the measure of a society is how it treats its most helpless members how does ours stack up when it subjects the mentally ill to a justice system that unfairly punishes them and a mental health system that fails them?  Mentally ill homeless people are not going away, but they need to go somewhere.  Can we as a society find the solutions and compassion to give them a place?