Essay: When Liberty Really Means Neglect

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Concern about the homeless usually waits for winter, when the cold weather claims its first victims and a frozen, abandoned death stirs guilt and some compassion.

Concern comes early this year. Last week a homeless woman walked into the Wall Street office of a currency-trading firm and shot the owner dead. In August she had been released from a mental hospital. Police say she was under the delusion that she was a partner in the company and had been wronged.

Guilt gives way now to fear. It is only autumn, but the annual question has begun to be asked: What are people like her doing on the streets?

They are the remnants of a grand and noble experiment.

The early '60s were heady days. Camelot, civil rights, new frontiers, war on poverty--and a social cure for mental illness. We would close the mental hospitals, empty the snake pits. Washington would create, ex nihilo, an entirely new system of care, planting mental health centers in every hamlet. New wonder drugs would control patients' symptoms. The community would welcome back its lost souls.

In 1963 John Kennedy signed the Community Mental Health Centers Act. Almost two centuries before, Philippe Pinel had struck the chains from the inmates of the Salpêtrière asylum in Paris; Kennedy unlocked the doors. What had until then been therapy--getting people out of the hospital and back to their community--became policy. Twenty years ago, almost half a million patients were in state mental hospitals. Three-quarters are now gone.

Gone where? Many, it is true, to a better life close to home. The rest to a life with no home. You see them on Main Street, foraging for food, sleeping in cartons. An army of grate dwellers.

How big an army? Some say that only about a third of the homeless are mentally ill. Studies done in Boston and Philadelphia, where psychiatrists interviewed the homeless in shelters, yield estimates as high as 85%. Yet only a small proportion, perhaps a quarter, of the homeless are former mental patients. So emptying the hospitals, the skeptics say, is not the major cause of homelessness. This is a non sequitur. The social policy mandating that old patients be pushed out of psychiatric hospitals also mandates that new patients be kept out. True, today's young schizophrenic is less likely than yesterday's ever to have been in a mental hospital. That does not mean that he is not mentally ill.

"A composite of studies [of the homeless] indicates that 35% have schizophrenia and 10% significant clinical depression," writes Dr. Irwin Perr of the Rutgers Medical School in New Jersey. And "some 25% to 50% have alcohol-and drug-abuse problems." Which means that, to be conservative, a majority of the homeless dwell near either psychosis or stupor.

Of course, not all. Some (for example, abandoned women with small children) are merely destitute. They are the victims of a declining housing stock, cuts in social spending, gentrification of poor neighborhoods. They need housing, not hospitals.

But what to do for those who are truly ill? A common response is: more. More money for local mental health centers. More services. More community. It is not that community mental health has failed, argue many of its defenders. It is that, as has been said of Christianity, it has never been tried.

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