October 2006 Thoughts

I can't point to the line that divides mind from body, because these concepts describe different aspects of the same thing. We are both. Locating your mind in your brain makes no more sense than locating your vision in your eyes: these are merely the organs that make these experiences possible. For example, every woman knows that men think with other organs than their brain.

I have faith that I have job security as a mental health professional because many mental disorders are currently poorly understood. Patients, who truly are suffering, sometimes complain to me that their medication, or the psychotherapy, or both - aren't working. This is because the most talented mental health professionals have no idea why people get most mental illnesses or how to "cure" them. We don't cure them. We try to interfere with symptoms and that's almost always the best we can ever hope for.

We have been bombarded in the US with drug company advertisements for pharmaceuticals that often oversimplify a harsh reality: we almost never know why anyone is depressed, anxious, has bipolar disorder, or any other number of mental disorders. We do know what these disorders look like and have some idea of what might help some people feel and function better. Some people, not all.

The technology mental health professionals have is limited and we are irresponsible if we don't thoughtfully try to manage the expectations of the people we try to help. Some people get better without treatment and not every mental disorder responds well to treatment. Thus, we have the phrase "chronically mentally ill." Chronic means incurable. These are people whose disorder renders them limited in ways that range from barely noticeable to severely disabled.

For the severely disabled, their quality of life depends upon how much treatment they get. The answer to how much they get, if they are homeless, is typically none. In case you don't know anyone whose family has been touched by this tragedy, take notice of the next homeless person you see. According to one report broadcast by PBS, perhaps 75% to 90% of homeless people in the US are chronically mentally ill. They are on the street because we emptied out most of our state mental hospitals decades ago with the best of intentions: more humane, community based treatment. Then we failed to properly fund community mental health, so now they wander our streets, sleep in cardboard boxes, and eat our garbage.

Where I live in Illinois, we have old man winter. Homeless people must accept some help and refuse to remain homeless or they freeze to death. In warmer places, this is not so, so municipal planners install benches with closely spaced armrests that prevent people from using them to sleep in parks. They go out of their way to invent additional architectural contrivances to discourage people from living in public. Because chronically mentally ill homeless people are unsightly, disturbing, smelly, scare the tourists, and drive down property values.

Enter the homeless shelter. Homeless shelters are appropriate places for temporary housing of otherwise able people displaced by tragedies. These people can and often do find their way back into society with some help. People who want to place chronically mentally ill people in homeless shelters may be well meaning, but they've got it wrong. It's a kind of reverse "not in my back yard" strategy. It displays an utter lack of understanding of the population they say they wish to serve.

It is of course nonsense to argue that three hot meals and a cot in a shelter are inferior to a cardboard box and a dumpster, but that ignores the reality that chronically mentally ill people have special needs. They aren't going to be cured or returned to independent productive lives in society. To have any hope of quality of life, they need medication, compassionately structured living environments, and medical supervision. It also ignores something else: in a homeless shelter, the person in the next cot, who isn't mentally ill, will probably not find the close company of an untreated schizophrenic comforting. It defies common sense to say these two people belong together. It's not safe for either of them. Neither will benefit.

Chronically mentally ill people belong in a therapeutic environment homeless shelters were never intended to provide. That's what community mental health centers are equipped to do. We should fund them to do it. Housing chronically mentally ill people in homeless shelters is a dirty trick. It's not urban renewal, it's urban removal of unsightly people we have historically shown no intention to help in a sustainable way. It's immoral to hide them in homeless shelters without treatment, while conveniently boosting the property values of the neighborhoods from which their old cardboard box homes have been quietly removed. It obscures from public view the national tragedy that we as a society have abandoned them.

People shouldn't protest building of homeless shelters. We should refuse to fill them with people who need mental health treatment. Shelter care people are doing God's work, but not if they indiscriminately house people who need mental health treatment with those who don't. If you think that's too much of a burden for them to sort out, I promise you it's not rocket science. I could teach a high school graduate how to compassionately and reliably tell the difference in half a day of training. Then they need a well funded community mental health center nearby to refer chronically mentally ill people for care.

Mental health treatment has a long way to go before it will be as effective as we would all like it to be. But we could be doing our best with the tools we have. No one need fear the chronically mentally ill, for they are usually of greatest risk to themselves. We need the courage to care for them rather than conceal them.

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