American Psychiatric Association Addresses the Homeless Mentally Ill Summary

  • Last updated on November 10, 2022

In a comprehensive report, the American Psychiatric Association described the possible causes of the problem of the growing number of homeless mentally ill in the United States and offered some suggestions for solutions to the problem.

Summary of Event

In colonial America, the homeless mentally ill were often transported from one village to another, in the hope that someone might care for them in another town. By the nineteenth century, this practice had given way to housing the mentally ill in large hospitals or asylums. Although these places were originally designed to provide treatment for the mentally ill, after a while asylums in the United States became more like warehouses in which the mentally ill simply existed. Conditions in these hospitals did not improve over time. In the 1970’s, these same hospitals began to discharge their patients, some of them to the nation’s streets rather than to proper homes. Mental illness;homelessness Homelessness American Psychiatric Association;homeless mentally ill Homeless Mentally Ill, The (Lamb) [kw]American Psychiatric Association Addresses the Homeless Mentally Ill (Oct., 1984) [kw]Psychiatric Association Addresses the Homeless Mentally Ill, American (Oct., 1984) [kw]Association Addresses the Homeless Mentally Ill, American Psychiatric (Oct., 1984) [kw]Homeless Mentally Ill, American Psychiatric Association Addresses the (Oct., 1984) [kw]Mentally Ill, American Psychiatric Association Addresses the Homeless (Oct., 1984) [kw]Ill, American Psychiatric Association Addresses the Homeless Mentally (Oct., 1984) Mental illness;homelessness Homelessness American Psychiatric Association;homeless mentally ill Homeless Mentally Ill, The (Lamb) [g]North America;Oct., 1984: American Psychiatric Association Addresses the Homeless Mentally Ill[05560] [g]United States;Oct., 1984: American Psychiatric Association Addresses the Homeless Mentally Ill[05560] [c]Psychology and psychiatry;Oct., 1984: American Psychiatric Association Addresses the Homeless Mentally Ill[05560] [c]Civil rights and liberties;Oct., 1984: American Psychiatric Association Addresses the Homeless Mentally Ill[05560] [c]Social issues and reform;Oct., 1984: American Psychiatric Association Addresses the Homeless Mentally Ill[05560] Donaldson, Kenneth Rogers, Ruby Ennis, Bruce Brown, Joyce Lamb, H. Richard

The deinstitutionalization of American mental hospitals Deinstitutionalization of mental hospitals was a complex process with various causes. Conditions within the hospitals were deplorable, but this fact became widely publicized only after World War II. In 1955, antipsychotic drugs were administered to patients for the first time. These produced dramatic and what were thought of at the time as beneficial effects. With the help of these drugs, it was thought that those on the “back wards” might he able to function outside the hospital. In the early 1960’s, several books were published that questioned the very concept of mental illness. In The Divided Self: A Study of Sanity and Madness (1960), Divided Self, The (Laing) R. D. Laing Laing, R. D. wrote that schizophrenics have devised an intelligible way to confront an impossible living situation in their so-called craziness. According to Laing, given that this craziness is perfectly understandable, the psychosis of schizophrenia might even be a higher form of sanity than sanity itself. In The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (1961), Myth of Mental Illness, The (Szasz) Thomas Szasz Szasz, Thomas declared that people who have been labeled as mentally ill merely have problems with living. Sociologist Erving Goffman Goffman, Erving suggested in Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (1961) Asylums (Goffman) that many of the symptoms that plague the mentally ill, such as apathy, are the result of being kept in hospitals.

These books had particular influence on the mental health bar, which came into existence during the 1970’s. Bruce Ennis led a group of lawyers who systematically brought suits throughout the United States to establish the rights of the mentally ill. In O’Connor v. Donaldson (1975), O’Connor v. Donaldson (1975)[Oconnor v. Donaldson] the U.S. Supreme Court decided that a mentally ill patient had the right to treatment. In Rogers v. Okin (1979), the federal courts granted patients the right to refuse treatment. One of the results of these cases was that in order to avoid liability in either of these instances, doctors found it easier to let patients leave the hospital than to attempt to get them to submit to proper treatment.

When these patients were released from the hospitals, the mental health bar, and particularly Ennis, worked hard to change involuntary commitment laws that could force former patients to return to institutions. Ennis succeeded in getting states to narrow the standards by which a mentally ill person could be committed involuntarily. The standard throughout the United States became that a person could be committed to a mental hospital against his or her will only if that individual posed a danger to self or others. As a result of these new laws, many mentally ill people who formerly were committable were left to their own devices, which in some cases meant living on the streets.

A final reason for the deinstitutionalization of the nation’s mental hospitals was the assumption by the federal government of some of the financial costs involved in hospitalization. In 1963, Congress passed the Mental Retardation Facilities and Community Mental Health Centers Construction Act, Mental Retardation Facilities and Community Mental Health Centers Construction Act (1963) with the intention that these new centers would take over the treatment and care of the patients being discharged from hospitals. In addition, those discharged became entitled for the first time to Social Security disability benefits. These funds would enable them to live in the community after leaving the hospital. This was the hope behind deinstitutionalization; the reality was quite different.

Many discharged patients went to live with their families. When this arrangement proved unworkable for some of the mentally ill, they found their way to single-room occupancy hotels. When many of these were demolished in the early 1980’s in the wake of urban renewal, many former patients turned to the streets. At this point, the government cut back on the benefits to which they had been entitled. Most problematic and troubling of all was the fact that during this period, this group, made up primarily of the chronically mentally ill, found little care offered at community mental health centers. Those who worked at the centers did not want to deal with the members of this population, whom they found too chronic, too resistant, and simply too difficult. Thus “bag ladies” and disheveled men yelling at voices only they could hear began to appear more frequently in the streets.

It was in this context that the American Psychiatric Association (APA) formed a task force on the homeless mentally ill in the early 1980’s. Dr. H. Richard Lamb, professor of psychiatry at the University of Southern California School of Medicine, led the group of nine members. Thirty professionals, including doctors, nurses, social workers, and one lawyer, contributed to the task force’s final report. The report, published in October, 1984, detailed many aspects of the problems of the homeless mentally ill.

Most of the contributors attributed the increase in the population of homeless mentally ill to deinstitutionalization. The population of mental hospitals had gone from 559,000 in 1955 to 150,000 in 1980. Given the mobility of the homeless population, the task force found it hard to determine how many homeless people had been patients in these hospitals and how many were currently mentally ill. The task force’s studies, which have been subject to some criticism, concluded that roughly 40 percent of the homeless were mentally ill. Figures concerning the size of the group ranged from 250,000 to more than a million.

The contributors to the task force report did not generally question the premises underlying deinstitutionalization. They said that the problem with the movement was the way in which it was implemented. They found that the community mental health centers had not planned effectively for the care of former mental patients. Lamb went even further by suggesting that the homeless mentally ill were in that situation because of their mental illness. He claimed that the chronically mentally ill who composed this group tended to form hostile dependent relationships with others. They feared the subsequent intimacy, needed to deny that dependence, and thus had a tendency to drift. This theory explained why living with families, as the discharged mentally ill originally did, or even attempting to seek any kind of treatment, if available, was fraught with difficulties. Lamb encouraged mental health professionals to begin to accept these dependence needs when dealing with this group.

Most members of the task force, when they spoke of any change in the involuntary commitment laws, spoke of these changes in terms of creating some kind of laws for commitment not to hospitals but to community care. The task force noted that twenty states had such laws at the time of their writing in 1984. Many believed that the general narrow standard of dangerousness by which a person could be involuntarily committed was inhumane, in that a person could be so psychotic that he or she could not properly meet basic needs or know whether he or she was in need of treatment.

The task force urged that many different groups assume more responsibility for the care of the homeless mentally ill. It urged that the mental health profession, particularly those in the community mental health centers, attend to the needs of this group more sensitively and carefully than it had done before. It urged lawyers to help in the enactment of more humane commitment laws. Finally, it urged the federal government to provide more funding for the homeless mentally ill.

Significance

It is difficult to pinpoint a direct impact of the APA task force’s report on the homeless mentally ill. Few observers have referred to the report in their writings since it was published. Estimates indicate that the population of the homeless mentally ill has grown, rather than diminished, since 1984. Nevertheless, significant events have taken place regarding the homeless mentally ill since the task force’s report appeared.

In 1987, Congress made an effort to assume its responsibilities to this group by passing the Stewart B. McKinney Homeless Assistance Act. Stewart B. McKinney Homeless Assistance Act (1987)[Stewart B. Mackinney Homeless Assistance] This act, later named the McKinney-Vento Homeless Assistance Act, McKinney-Vento Homeless Assistance Act (1987)[Mackinney Vento Homeless Assistance Act] provided for a broader range of housing, health care, multiservice centers, employment programs, and self-help groups than previously. The act required the mental health profession to assume more of a role than it previously had played. In some areas, such as St. Louis, Missouri, such attempts were successful.

Problems remained concerning involuntary commitment laws. By 1991, only Kansas had broadened its laws beyond the standard of dangerousness. In 1985, Edward I. Koch, Koch, Edward I. then mayor of New York City, began to send out police to round up the homeless mentally ill during the winter. Mayor Koch granted the police emergency powers to commit those rounded to mental hospitals, from which they eventually would be released to community care. In 1987, Joyce Brown successfully challenged this law. Hospitalized and disguised as a paranoid schizophrenic in 1984, this young black woman had taken up residence on the streets of New York by 1986. In 1987, several citizens called the authorities and complained that she was shouting obscene epithets at men and urinating and defecating on the sidewalks. Police picked her up and committed her to Bellevue Hospital. She won her release later in court and then proceeded to speak on several talk shows and at Harvard on her right to remain free in the community, if not in the streets. She was found again, yelling more insults to men, a year later.

Some people argued that the solution to the problem of the homeless mentally ill was to change the commitment laws and rehospitalize this group. Others objected to the involuntary incarceration of the blameless. Many of the homeless mentally ill themselves indicated strongly that they preferred to live, if not to die, on the streets rather than return to hospitals.

In many ways, the problems of caring for the homeless mentally ill remained as intractable as they were when the task force issued its report. The major problem remained finding someone to assume responsibility for the chronically mentally ill. Mental health professionals as a group disliked dealing with this population. Some activists tried to change the commitment laws, mainly at the behest of families of mentally ill persons. Others brought right-to-shelter cases, which achieved neither positive results nor favor with the public. For the most part, the public in general was inclined to ignore the homeless mentally ill, who served as living reminders of the nation’s poverty and pain. That left the government, faced with its own fiscal problems, to cut back on existing programs instead of creating new programs. Mental illness;homelessness Homelessness American Psychiatric Association;homeless mentally ill Homeless Mentally Ill, The (Lamb)

Further Reading
  • citation-type="booksimple"

    xlink:type="simple">Cohen, Neal L., ed. Psychiatry Takes to the Streets: Outreach and Crisis Intervention for the Mentally Ill. New York: Guilford Press, 1990. A collection of interesting and well-written essays. Valuable insights on deinstitutionalization. Not all of the essays deal with the homeless mentally ill. No mention of the APA task force.
  • citation-type="booksimple"

    xlink:type="simple">Goffman, Erving. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Garden City, N.Y.: Anchor Books, 1961. A collection of essays describing the phenomenon of institutionalization, whereby a mental patient acquires symptoms not because of illness but because of being incarcerated in what the author defines as a total institution. The book encouraged the move toward deinstitutionalization.
  • citation-type="booksimple"

    xlink:type="simple">Isaac, Rael Jean, and Virginia C. Armat. Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill. 2d ed. Arlington, Va.: Treatment Advocacy Center, 2000. A forceful and thorough account of how the mentally ill became homeless. Offers a clear indictment of the role psychiatry and the law played in this crisis. The authors say that any civil rights the mentally ill may enjoy merely disguise their neglect. The authors support redesign of commitment laws. No mention of the APA task force.
  • citation-type="booksimple"

    xlink:type="simple">Johnson, Ann Braden. Out of Bedlam: The Truth About Deinstitutionalization. 2d ed. New York: Basic Books, 1992. An impassioned account describing the homeless mentally ill by a social worker who works with them. Highly critical of the mental health profession, which has refused to care for this group, and the mental health bureaucracy, which is too far removed from its clients. Contains a history of deinstitutionalization similar to the account of Isaac and Armat. No mention of the ABA task force.
  • citation-type="booksimple"

    xlink:type="simple">Johnson, Kelley, and Rannveig Traustadottir, eds. Deinstitutionalization and People with Intellectual Disabilities: In and out of Institutions. Philadelphia: Jessica Kingsley, 2005. Personal narrative and professional analysis offer a comprehensive overview of deinstitutionalization. Discusses a range of institutions, including nursing homes and jails.
  • citation-type="booksimple"

    xlink:type="simple">Laing, R. D. The Divided Self: A Study of Sanity and Madness. London: Tavistock, 1960. Suggests that those who have been proclaimed “mad” have created an understandable and intelligible world in reaction to a mad existence. Thus, there is a real sanity in alleged madness, which gives rise to the question whether mental illness or insanity really exists.
  • citation-type="booksimple"

    xlink:type="simple">Lamb, H. Richard, ed. The Homeless Mentally Ill: A Task Force Report of the American Psychiatric Association. Washington, D.C.: American Psychiatric Association, 1984. Comprehensive collection of essays addressing the problem of the homeless mentally ill. Much discussion about the failures of deinstitutionalization as implemented and how this group needs care in community settings. Although the report makes many recommendations, it makes few practical suggestions.
  • citation-type="booksimple"

    xlink:type="simple">Ropers, Richard H. The Invisible Homeless: A New Urban Ecology. New York: Insight Books, 1988. A well-written and thoughtful book using economic, social, and political theories to explain the homeless mentally ill. Mentions the task force and is critical of some of its conclusions. Deals mainly with the problem in Los Angeles, California, but refers to other parts of the country. A balanced account that challenges those with more psychological explanations.
  • citation-type="booksimple"

    xlink:type="simple">Szasz, Thomas S. The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Hoeber-Harper, 1961. Argues that those who have been called mentally ill merely have problems in living; thus, there is no such thing as mental illness. The libertarian views expressed influenced psychiatric and legal professions toward deinstitutionalization.
  • citation-type="booksimple"

    xlink:type="simple">Torrey, E. Fuller. Out of the Shadows: Confronting America’s Mental Illness Crisis. New York: John Wiley & Sons, 1998. Drawing on decades of research, the author blasts the concept of deinstitutionalization and society’s failure to provide adequate treatment for people with severe mental illnesses.

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