WASHINGTON, DC — “I used to see auras, but I thought they were signs from God.”
Walter is a 54-year-old DC resident with schizophrenia who has asked me to withhold his last name. When he became seriously symptomatic at the age of 19, he — like many Americans who suffer from a serious mental illness — didn’t even realize he was sick. “I thought it was more of a spiritual nature,” he told me.
Now, after 35 years and a life-saving intervention by a local homeless mental health organization called Pathways to Housing DC, Walter is in recovery. He’s the father of a five-year-old girl, interviewing for jobs, and his son just graduated from college with a business degree. But the road to this moment involved traversing decades of poverty, 24 different doctors, dealings with state psychiatric institutions, and prolonged bouts of homelessness. His story highlights the myriad shortcomings in affordable housing and mental health care policies that often leave the homeless and mentally ill without much of a shot in life.
Living on the streets with a mental disorder can often be a hellish experience. Walter described days filled with long walks and prayer, occasionally punctuated with interventions by police officers who took him to psychiatric hospitals, and, at times, violence. “I prayed a lot. I didn’t really know what I was going through. I wasn’t eating properly. All I know is that prayer kept me going.”
He usually avoided homeless shelters, apprehensive of the type of people that frequented them. Those fears proved to be sadly justified. Around Walter’s 45th birthday, a group of men at a shelter he went to sneaked in alcohol, got drunk, and beat Walter so badly that they broke his jaw. The police escorted him to the St. Elizabeth psychiatric facility in DC, where was able to sign himself in. “The hospital came in between me and being homeless,” he said, his voice growing somber.
The psychiatric facilities that Walter cycled through when he was homeless usually kept him in a drug-induced haze. He told me that the first such hospital he checked himself into as a teen forcibly medicated him. “I didn’t want to take the medicine because I thought it wasn’t pure. So what happened was they gave me a shot, and I was unconscious for about three days,” he said. That experience sowed a mistrust of the psychiatric care industry that would take Walter years to overcome, at first only out of an overwhelming need for shelter.
A decade later, a very different kind of organization is helping Walter stay off the streets. Pathways to Housing is a part of DC’s diverse and expansive mental health provider network. According to Steve Baron, director of the city’s Department of Mental Health (DMH), this network provides care for approximately 22,000 mentally ill Americans over the course of a year. It’s also undergone major transformations since 2008 that have shifted resources away from the government and into local programs. “About 4 or 5 years ago, 30 percent to 40 percent of the mentally ill were served by government. We’ve transferred a lot of that to the community providers and have made every effort to expand needed services,” Baron told me.
Mental health care advocates often argue that these community-based programs are more effective than a long and costly hospitalization — particularly for vulnerable groups like the homeless. Christy Respress, the executive director of Pathways, explained that a big reason for that is that giving stability to mentally ill Americans experiencing homelessness by finding them affordable housing is the most crucial step in their recovery. “It’s housing first. Housing ends homelessness — it’s pretty straightforward. It doesn’t cure mental illness and it doesn’t cure addiction, but what it does is that it gives the human being who’s living with those issues the safety and stability of a home so that they can begin to be able to deal with those issues… With a home, people start wanting to address [the mental health issues] naturally.”
Pathways receives referrals through DMH and employs special groups of case workers called Assertive Community Treatment (ACT) teams that identify, find housing for, and eventually treat the mentally ill homeless men and women who populate DC. The organization has about 250 participants currently living in apartments and receiving treatment, with another 50 or so at some stage of moving in or being approached about the program. Approximately half of the organization’s 80-person staff serve on the ACT teams.
Walter got word that he qualified for the program from one of these ACT team members while he was in the hospital. “She told me that the government has the funds for people like me that were homeless… She showed me a couple of different apartments.” Although that might have sounded a bit too good to be true, Walter said that he believed her because, unlike many of the doctors he dealt with throughout his life, “she explained [things] to me.”
Not everyone is quite so trusting from the get-go. Pathways must often foster personal relationships with the people they approach since some can be instinctively mistrustful of outreach organizations such as theirs. That may involve meeting very basic needs by bringing them items of clothing or food until they agree to join the program. “Maybe it’s a pair of socks today. And maybe a granola bar the next. It’s about building trust,” said Pathways’ director of development, Hannah Zollman. “Often, people on the street really feel like they’re at the bottom of the totem pole.”
After that initial outreach in the hospital, Pathways’ housing department helped Walter find a suitable affordable housing unit that he pays for with the help of a Section 8 housing voucher. He was simultaneously enrolled into Medicaid and started getting the treatment and medication he needed.
But recovery doesn’t end there for Walter and his fellow Pathways participants. ACT team members meet with the people they care for on an average of two hours per week (although the number depends on a person’s individual need). They may help the newly housed individual learn how to grocery shop or cook. Walter may opt to have one of his caretakers accompany him to his job interviews if he wants, Zollman tells me. Some of those types of services don’t have a traditional Medicaid billing code, but they’re crucial to helping the formerly homeless return to housed life.
If that level of personal care sounds expensive, that’s because it is. Pathways’ Housing First services cost about $25,000 per year per person, split approximately half and half between housing and the mental health services provided by the ACT team.
But that’s far less expensive — and as Walter’s story shows, less risky — than funneling the homeless and mentally ill into shelters, which costs about $40,000 per person over the same amount of time. Ditto for the prison system, which has increasingly become a major mental health care provider in the face of state and federal budget cuts. Staying in the sorts of inpatient facilities that Walter cycled through over the course of his life runs about $700 per day.
Although historically low Medicaid payments to mental health providers remain a challenge for community organizations, Respress and Baron both say that the biggest barrier to innovative programs such as Pathways is a dearth of affordable housing and funding for Section 8 vouchers. Since 2000, the number of affordable housing units in the city has been cut in half, and DC’s apartment rental rates spiked more between 2007 and 2010 than they did in the preceding seven years. “It’s bad,” said Respress.
Rents may have risen, but the amount of money disbursed through housing vouchers hasn’t. That means low-income property owners have had to pick up an increasing share of the tab for their rent. The Department of Housing and Urban Development (HUD) may also have to cut back on the funding it gives to so-called “continuum of care” programs, which offer the sort of specialized services that Pathways does for the mentally ill and homeless, due to cuts from the federal budget sequester.
“Because of sequestration, we are not able to provide new projects like we have in years past,” HUD employee Laura Kunkel told me, stressing that she is not an official spokeswoman. “We weren’t even sure if we would have enough money to cover all of our renewals this year.”
HUD was ultimately able to fund all of this years’ programs — but they may not be able to do so in the future. The sequester instituted a five percent cut to every line item in the HUD budget, and the White House Office of Management and Budget applied further cuts with a rescission.
But the mentally ill and homeless working with Pathways can rest assured that they can continue working on their recoveries — likely successfully. The program’s recidivism rate is only around 15 percent. Walter has had to visit an inpatient facility just twice in the five years that he’s been working with the organization.
Asked about his favorite part of recovering living in his own apartment, Walter smiled at me and said, “I like being able to cook for myself.”