Essay: When Liberty Really Means Neglect

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.

Now, in principle, of course the “community” is a better place for the mentally ill than the hospital. But in practice, one is obliged to ask: What community?

Perhaps there once was a Rockwellian community ready to welcome its eccentrics. But in vast urban centers the mobility is dizzying, the competition fierce, and even the most stable can barely stand the stress. On Broadway’s median strip, what can the idea of community possibly mean? Even the most tightly knit community has trouble keeping its marginal souls intact. It is inevitable that in the restless churning of urban life, people with severe mental impairments will be crushed and will fall, quite literally, by the wayside.

“In many places,” says one mental patients’ advocate, “it’s worse than in the Middle Ages, when at least some communities cared for their mentally disabled and did not ostracize them.” In Greenwich Village last winter, barbed wire was placed across hot-air grates to keep homeless people from sleeping in the neighborhood. Arson destroyed a shelter for the homeless in downtown San Diego. A Fort Lauderdale city commissioner suggested rat poison as a topping for local garbage.

These are detestable cruelties, but why the surprise? Tolerance for deviance is a high ideal. To base social policy on the assumption that the ideal exists is to invite catastrophe.

Interest in the catastrophe of others, however, is hard to sustain. But when one of the homeless mentally ill puts a bullet in one of us, we listen. For our own safety, we may soon be ready to lock these people away.

Yet the homeless mentally ill are hardly a major public safety threat. They do get arrested more often than others, but mostly for misdemeanors. They tend much more often to be the victims of crime than the perpetrators. The overwhelming majority are simply too crazy to be dangerous.

The danger posed by the homeless to society is more subtle. Sociologist James Q. Wilson has advanced the “broken-window theory”: one broken window in a neighborhood is a kind of announcement that this is a place where care is not taken. And when order breaks down, everything else–vandalism, crime, ultimately total disintegration–follows.

The homeless–human litter in the streets–are a kind of broken social window announcing that suffering and chaos will be tolerated amid the most manicured lawns. Vagrants and panhandlers declare that the cycle of urban decay is under way. As formal controls break down, muggers move in, and stable families move out. “Arresting a single drunk or a single vagrant who has harmed no identifiable person seems unjust and in a sense it is,” writes Wilson. “But failing to do anything about a score of drunks or a hundred vagrants may destroy an entire community.”

There is one more reason people want the homeless carted away. People need to protect the mundanity of life. They cannot live with their feelings under challenge day in and day out. Living in the midst of the wretched homeless offends not just a community’s sense of aesthetics but its moral sense. It is deeply disturbing to climb over an immobile body on the sidewalk. Most people, if on one occasion they see one person lying in the street, will rush to help. But if that person, and a dozen others, return night after night, only the saintly can be counted on not to lose heart.

Shall we cart the homeless away? Sleeping on the sidewalk disturbs the neighborhood. It disturbs the universe. But reasons of tidiness or moral injury are simply not enough. In a free society, to deny freedom to people who have harmed no one, a better reason is needed.

There is one.

“We’re talking not [about] people who by reason of choice want to be vagabonds or hobos, or some other romantic idea of homelessness,” says Dr. John Talbott, former president of the American Psychiatric Association. “These people are in the streets because they cannot think straight, make decisions and organize their lives.”

The mortality rate for the homeless mentally ill is three times the normal rate. They suffer enormous abuse, indignities, illness of all kinds. They continue to suffer in revolving-door shelters, the vast majority of which offer virtually no medical, let alone psychiatric, care. And no respite: shelters are routinely emptied every morning to keep the beds free for the coming night. That means a daytime of wandering, every day.

Last winter New York’s Mayor Ed Koch decreed that when the windchill factor fell below 5°, the homeless would be taken to shelters whether they liked it or not. This winter the order goes into effect when the temperature merely falls below freezing.

Why not make compassion an all-weather policy? Danger should not be the only warrant for giving someone, even an unwilling someone, shelter and care. Degradation–a life of eating garbage, of sleeping on grates, of recurrent illness and oppressive hallucinations–should suffice.

There is a reason for forcibly removing the homeless mentally ill from the streets: not society’s fear of what the homeless are doing to us, but concern about what they are doing, cannot help doing, to themselves. In a society that aspires to be not only free but humane, removing the homeless mentally ill should be an act not of self-defense but of compassion.

It is not enough to remove them from the streets just to an overnight shelter. And the community has demonstrably failed them. They need protection and care and order. They need asylum.

Asylum conjures up snake pits, lobotomies, a cuckoo’s nest of horrors. But it need not be that way. Indeed, it has not always been that way. In psychiatry’s prescientific era, mental hospitals were truly asylums. All that could be offered mental patients was an environment of safety, fresh air and vigorous activity. “Moral treatment” was the basis of the asylum movement of the 19th century. It was the 20th century and the first inklings–and misapplications–of an infant science of psychiatry that brought on the horrors of pseudo treatment and medical abuse.

Psychiatry is no longer in its infancy. Treatments are much more sophisticated, practitioners more discriminating. Good care can have remarkable effects. “Once people are given a minimum of security, regular food and clinical attention,” says Medical Anthropologist Kim Hopper, “within a few weeks a remarkable alleviation of symptoms can eventuate.” Moreover, the mentally ill get worse on the street. Think of what a life on Broadway would do to you.

Partly because country life was thought to be healthier, the asylum has traditionally been located there. It need not be. Older urban hospitals, now being closed, could be turned into institutions to care for the homeless mentally ill. There is no need for warehousing. Smaller-scale urban or suburban clinics will do. The crucial feature of asylum is not isolation or size. It is control.

The civil libertarians will protest this control. They already are protesting. When Koch announced his roundup plan, he was vigorously opposed by the American Civil Liberties Union.

Liberty counts for much, but not enough to turn away from those who are hopelessly overwhelmed by the demands of modern life. To permit those who would flounder even in the slowest lane to fend for themselves on very mean streets is an act not of social liberality but of neglect bordering on cruelty. In the name of a liberty that illness does not allow them to enjoy, we have condemned the homeless mentally ill to die with their rights on. –By Charles Krauthammer