Pat Morgan: An Update

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To go with this week’s Flyer coverage of The Concrete Killing Fields, Pat Morgan’s first-person account of her work with the homeless in Memphis, I asked the author about an important point she makes throughout the book: inadequate mental-health services for the homeless in the wake of decades of deinstitutionalization of the mentally ill.

Go to Mother Jones for a useful timeline of events that saw the emptying of public psychiatric hospitals in favor of community-based, state-funded outreach programs. The timeline is subtitled "How deinstitutionalization moved thousands of mentally ill people out of hospitals — and into jails and prisons," and pay particular attention to the year 1984.

That timeline ends in 2010, and rephrase the subtitle to read: "into jails and prisons or onto the streets." Which is why I asked Morgan to bring us up to date on mental-health services for the homeless generally and what’s being done — and needs still to be done — for the homeless in Memphis and Shelby County:

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Is the U.S. any better today at meeting the mental-health needs of the country's homeless?
Pat Morgan:
No, but it’s not the fault of the mental-health professionals who are doing everything they can for as many people with mental illness as they can. They know what needs to be done and how to do it, but they don’t have the funding for the number of mental-health outreach workers needed to go to the streets, shelters, and jails to try to connect homeless people with mental illness to services, benefits, and housing.

A total of 55,147 mentally ill people were found sleeping “unsheltered” during the 2013 national point-in-time count of homeless people. We don’t know how many of them “lack insight” into their illness and/or the conditions in which they are existing and therefore can’t, or won’t, accept shelter, much less mental-health treatment. An additional 69,005 mentally ill people were in shelters or transitional housing programs for homeless people.

We worry about all of them. We don’t have to worry nearly as much about those who have been deinstitutionalized, because it’s almost impossible to get someone involuntarily committed. If you’ve never been institutionalized, you can’t be deinstitutionalized. And I’m not the only one who says so.

Dr. E. Fuller Torrey, who endorsed The Concrete Killing Fields, is the executive director of the Stanley Medical Research Institute and founder of the Treatment Advocacy Center, a nonprofit dedicated to “eliminating legal and clinical obstacles to the treatment of severe mental illness.” “It’s almost impossible to get someone involuntarily committed,” he said in a recent interview.

Is the case today that government funding for mental-health programs is even harder to come by than it was?
Absolutely, and some of the nation’s leading mental-health advocates, including the Bazelon Center for Mental Health Law, the National Association of State Mental Health Program Directors, and the National Alliance on Mental Health have the data to prove it.

All three have recently published or updated reports reflecting the decreases in funding for mental health by the states that began when Medicaid began paying for mental-health services, decreased again in 1981 when Congress replaced direct funding of mental-health centers with a block grant, and decreased again when the markets and economy began crashing in 2007.

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Medicaid is now the largest payer of mental-health services in the U.S., and the costs would be even higher if people weren’t so afraid of the stigma associated with mental illness or were willing or able to accept treatment. The federal government’s Substance Abuse and Mental Health Services Administration reported in 2010 that 40 percent of people in the U.S. with a serious mental illness had received no treatment in the past year. Dr. Torrey’s research reflects the nightmarish results for many of them: “There are now more than three times more seriously mentally ill persons in jails and prisons than in hospitals.”

What the report didn’t describe were the inhumane conditions under which some of them are held. I contend that purists who insist on an individual’s absolute right to freedom, regardless of his/her mental state, have not contemplated the freedom to be incarcerated.

What steps are Memphis and Shelby County taking to improve the homeless situation?
There are quite a few. The steadily increased development of permanent supportive housing for homeless people with a disability has resulted in a significant decrease in the number of those who are chronically homeless, primarily defined by HUD as having slept in shelters or on the streets or other places not meant for human habitation for a year or more.

There’s also been a significant decrease in the number of homeless veterans. The Community Alliance for the Homeless also reported a decrease in the number of homeless families. That statistic no doubt reflects a greater emphasis on prevention and the closing of approximately 60 units of transitional housing for homeless families with children, which are now set aside for permanent supportive housing for homeless families who are involved with the State Department of Children’s Services — that is, have children in foster care or are at risk of losing custody of their children.

What, in your opinion, is the most pressing need?
There are many, but I would argue that the most pressing need is funding from a reliable source to help ensure that people with serious mental illness who lack insight into their illness, refuse treatment, and are therefore at great risk of becoming homeless and/or incarcerated receive the mental-health treatment and services they need in the least restrictive setting.

I’d propose that Memphis and Shelby County partner with local foundations and mental-health providers to fund, develop, and implement a pilot program to test the efficacy and cost-effectiveness of Assisted Outpatient Treatment as a means of preventing/reducing homelessness, institutionalization, and undue incarceration resulting from untreated mental illness. There are models that actually work — if and only if they are adequately funded and administered.

I believe in Memphis, Shelby County, our foundations, the state of Tennessee’s Department of Mental Health, and local providers of mental-health services. I think they can make it work. •

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