It was 9 o’clock at night, and a quiet calm had transcended over the homeless shelter. The harsh fluorescent lights were turned off as the residents retreated to their bedrooms for the night with drooping eyes. Moonlight shone through the skylights in the second floor ceiling, causing a glow that was haunting and dreamlike.
On a typical night like this I would also be winding down, eagerly awaiting 10 p.m. when my shift would end and I could retreat home to climb into bed. But tonight was different. Instead of listening to the gentle hum of the electronic appliances while sitting safely in my office, I was standing outside of the second floor bathroom, trying to coax Tina[i] out of the shower. Her panicked screams and desperate sobs echoed in the otherwise quiet hallway, piercing through my ears and into my soul. The agony in her voice made me want to cover my ears and run, but my feet stayed rooted to the ground as two male police officers paced around the shelter, waiting for the arrival of the mental health crisis worker who had initially refused her responsibility to come and evaluate Tina.
The screaming started about an hour before, after a long and painful evening, and a lengthy and trying two months. Tina had shown up at our shelter a few months before, and although we didn’t have the staff or expertise needed to treat her severe mental illness, we also knew that the alternative—a life on the lonely, harsh Denver streets—would be even worse. Our attempts to find her mental health treatment had fallen short, and tonight was our last chance to get her the help she needed. A few hours earlier she had hit me out of anger, breaking our no-exceptions rule that violence was not tolerated. It took everything I had to fight the urge to lock myself in my office and wait out the rest of my shift to instead try my best to connect her to inpatient emergency mental health treatment on the grounds that she was a danger to others. I knew that if my attempt failed, she would be sleeping on the snowy streets the following night.
Tina’s story is not unlike the story of many other women who walk through the doors of our shelter, or of men and women who are sleeping on the streets or in other homeless shelters across the U.S. On any given night, one-third of people experiencing homelessness have severe mental health issues,[ii] and an estimated 40% of people with mental illness are not receiving the treatment they need.[iii] Lack of health insurance or ability to pay for health services, long wait lists for mental health treatment, insufficient funding for mental health programs, and services that don’t meet the unique needs of patients all contribute to difficulties treating people with mental illness.
In a study of 25 cities in the U.S., mental illness was ranked as the third largest cause of homelessness for single adults.[iv] Homeless individuals with mental health issues are especially vulnerable: 74-87% have been victims of violent crimes during their homelessness. 3 Homelessness is already a complex experience with many layers of overlapping causes, but mental health further complicates finding a solution.
When Tina came to our shelter, she was only 19 years old. She needed more care than her family could provide, and had recently been discharged from a state-run psychiatric hospital. Observing Tina for even just a few hours made it clear that she was severely disabled because of her mental health issues, and was likely experiencing one of her first psychotic breaks.
We tried using every known resource to find mental health treatment for Tina, but without income or health insurance and scarce mental health services for the homeless in Denver, we encountered barrier after barrier. About a month into her stay, she was evaluated and put on an emergency mental health hold for being gravely disabled by her condition (in Colorado, an involuntary 72 hour mental health hospitalization can also be triggered by being a danger to self or danger to others), but she was discharged early. In the final weeks of her stay we were finally able to contact a community mental health agency, who came to evaluate Tina. However, Tina didn’t show up for her initial intake, so our efforts to connect her to services were further delayed.
Chronic, severe mental health issues are difficult to treat, and are especially difficult when an individual is homeless. How can you prioritize your mental health when worrying about where you will sleep the next night, or where your next meal will come from? Mental health medications are valuable commodities, and many homeless individuals fall victim to theft as their pills are stolen to be sold on the street. Additionally, the longer mental health conditions go untreated, the more difficult they are to treat. Without access to care, individuals often “self-medicate” by using street drugs such as heroine or crack cocaine to cope with their symptoms. An estimated half of people who are homeless with mental health issues have co-occurring substance abuse issues, making it even more difficult to find the services and stability they need. 3
Treating homelessness and mental health issues at the same time is difficult, but not impossible. Housing First is a national model that has shown success. [v] These programs quickly provide housing paired with supportive services such as physical and mental health treatment, case management, and life skills classes. Participating in these services are optional, and housing isn’t contingent on participation. Additionally, the expansion of Medicaid (state-funded health insurance for low-income individuals) has increased access to health insurance and health services, and community health clinics that provide integrated care have expanded the availability of mental health treatment. Solutions exist, but only if we decide that the programs are worthy of funding.
At about 10 p.m. a mental health worker finally arrived and Tina was put on a mental health hold based on the diagnosis that she was a danger to others and gravely disabled by her mental illness. I had to inform the mental health worker that Tina was not allowed to return to the shelter because she had been violent. I cried in my office as they escorted her out, the first time in over three years of working at the shelter that I let my guard down enough to let the residents see my emotions so exposed. My tears were rooted in relief that the night was over and knowing that Tina was receiving a chance at treatment, and because of the injustice of what it took for her to receive it.
After Tina’s hospitalization, she was transferred to an in-patient mental health treatment center for young adults. She was one of the lucky ones; many homeless individuals who are hospitalized for mental health are discharged back to the streets after 72 hours.
People with mental health issues deserve greater priority. Integrated healthcare services that treat mental health as well as physical health, widespread education about mental health, and housing programs that provide supportive services are essential. We cannot settle for a system that requires someone to hurt themselves or someone else before they receive the care they need. The state of our mental health system urgently, desperately needs to change, so that all people can live the type of life they deserve.
[i] Name changed to protect confidentiality.
[ii] Treatment Advocacy Center. (2014). How Many Individuals with a Serious Mental Illness are Homeless? Retrieved from http://www.treatmentadvocacycenter.org/problem/consequences-of-non-treat....
[iii] National Health Care for the Homeless. (2000). Mental Illness, Chronic Homelessness: An American Disgrace. Healing Hands, 4 (5). Retrieved from https://www.nhchc.org/wp-content/uploads/2012/03/Oct2000HealingHands.pdf.
[iv] National Coalition for the Homeless. (2009). Mental Illness and Homelessness. Retrieved from http://www.nationalhomeless.org/factsheets/Mental_Illness.pdf.
[v] U.S. Department of Housing and Urban Development. (2007). The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness. Cambridge: Abt Associates Inc. Retrieved from https://www.huduser.gov/portal/publications/hsgfirst.pdf.