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When Helping the Homeless
Means Treating The Homeless

By Michael Hyde

Today, Russell D’Arpa has permanent residence at the Independence House. He combats his illness with medication, which allows him to function within the community and stay out of the shelter system.
Today, Russell D’Arpa has permanent residence at the Independence House. He combats his illness with medication, which allows him to function within the community and stay out of the shelter system.
The old Fort Washington Shelter housed more than 1,000 homeless men.
The old Fort Washington Shelter housed more than 1,000 homeless men. Before New York's shelter system was revamped in the early 1990s, this converted armory building on 168th Street saw rampant crime, wide use of drugs and alcohol, and untreated mental illnesses.

Russell D'Arpa was never a bum. Nor was he a panhandler, hobo, or tramp. And even though he was out of work, out on the streets, and seemingly out of touch with reality, these harsh slangs did not apply to this man who wandered from shelter to shelter in New Jersey and New York, for years. Simply put: Russell was sick and needed help.

'He had a very treatable illness, but he just hadn't received that treatment,' says Dr. Alan Felix, associate clinical professor of psychiatry and director of the Critical Time Intervention (CTI) Mental Health Program at the Fort Washington Shelter. Dr. Felix knows that people like Russell who are mentally ill are at a high risk of becoming homeless. He also has seen how treating this illness with the help of the CTI program can give people like Russell a chance to return to the community, thus reducing homelessness among the mentally ill.

The program is aimed at helping men who are homeless because of schizophrenia, affective illnesses like bipolar disorder, or severe depression. Through CTI, these men receive proper medical treatment and move to community housing where they attempt to live independent of the shelter system.

When Russell was in his 20s, he did not seem like someone who would spend any time in a shelter. He lived in an apartment in New Jersey near his parents, brothers, and sisters. He owned his own business and was engaged to be married. But in the early '80s his mother died, his business failed, and he broke up with his fiancé. He tried to make a living selling copiers but couldn't earn enough to pay rent. He started to bartend at night to supplement his income, but that job was only temporary. Russell fell into a deep depression. Although he doesn't recall why, his records show that he was hospitalized three times-possibly for psychotic episodes.

After losing his apartment, Russell moved into a basement dwelling in a building his father owned. By this time, Russell's problem had gotten worse. 'I heard voices talking to me, asking me questions,' he says. 'I also thought the radio was talking to me. I didn't know what was going on.' His father grew upset with him for bothering the other tenants. 'I didn't think I was bothering anybody, but I guess he did,' he explains. 'I didn't want to be a burden so I left.'

Dr. Alan Felix, center, participates in regular staff meetings with CTI case workers where they share updates on the men they treat.
Dr. Alan Felix, center, participates in regular staff meetings with CTI case workers where they share updates on the men they treat.
When Russell took to the streets, he had few options. 'I basically just walked around,' he says. 'I think I eventually found a shelter in Paterson.' Few of the shelters for the homeless in New Jersey and New York during the early '80s offered treatment for the mentally ill. Instead of receiving medical attention, people like Russell were given meals and a place to sleep. They shared these facilities with individuals who were criminally insane, addicted to drugs, or prone to violence and other criminal activity-sometimes a combination of these traits. While he was taking a shower at a Jersey City shelter, all of Russell's money was stolen from his pants pocket. Looking back, Russell feels he was lucky not to be the victim of more serious crimes, and he was also fortunate-and smart-enough to steer clear of drugs and alcohol. But his illness remained untreated.

At the same time, the Fort Washington Shelter did not offer much more than any other shelter. Located in the armory on West 168th Street, it housed as many as 1,000 homeless men, providing no specialized treatment for mentally ill residents. But that changed in 1986, when the New York City Department of Mental Health funded the Community Support System program to offer mental health treatment for the homeless. The city contracted with Columbia-Presbyterian's Department of Psychiatry and the Fort Washington Shelter housed the Columbia-Presbyterian Mental Health Program.

'Columbia's program was one of the first to offer mental health on site,' Dr. Felix explains. 'It was a fairly new concept back in the '80s.' The on-site treatment was helpful to many homeless men. The ones who responded well to the program were moved out of the shelter and into independent housing-usually single room occupancy hotels or supervised adult homes, in which the rent was paid by Social Security, welfare, or other assistance programs. At first specialized housing was limited. Many of the facilities were rest homes for the elderly that also accepted these men. But that changed in 1990 with the New York/New York Housing Program. This collaborative effort of New York City and New York state created more than 5,000 specialized units.

A new problem revealed itself-this time from the Community Support System's success. Many of these men had difficulty making the transition from life in an institution to life within the community. When they left the shelter the men faced a new set of problems: They had no one to tell them when to take their medication; they were left to their own devices to manage their money, which included making sure the funds they received were used to pay their rent on time; the risk of drug and alcohol abuse relapse increased; and their social surroundings changed from the shelter and its inhabitants and staff to members of the community, including housing directors and neighbors. Many of the men could not cope with these new challenges, suffered relapses, lost housing, and wound up back on the streets.

'In 1990, we received a grant from the National Institute of Mental Health, and we were able to extend our services to include a nine-month follow-up program,' says Dr. Felix. This additional funding led to the establishment of the CTI program to combat the problem of recurrent homelessness among the mentally ill. The program was administered to a randomized group of men at the Fort Washington Shelter between 1990 and 1994 as part of a research study. After the results demonstrated a reduction in homelessness, the experimental CTI program was extended to all the men in the Community Support System program.

Around the same time of the study, New York's shelter system was about to undergo several changes. During the early '90s advocacy groups filed a lawsuit against the city alleging poor conditions in its shelters. Dr. Felix testified during those proceedings and brought to light the dangerously high number of men being housed in the Fort Washington Shelter. Even if the dense population did not result in poor overall health and rampant crime, the mere numbers signaled fire code violations. Another change came from the New York State Reinvestment Act. This legislation reinvested funds from closed New York state hospitals into mental health programs. Finally, the Fort Washington Shelter was privatized and run-as it is today-by Project Renewal, a private, not-for-profit group.

All of these changes resulted in a facility that was transformed from a crowded, chaotic melting pot of every kind of transient to a few focused programs, including CTI, that treated a select group of 200 mentally ill homeless men.

When Russell was referred to the Fort Washington shelter from Bellevue in 1994, he was having conversations with imaginary voices in his head. These episodes led to shouting. He also was convinced that a dentist had implanted an electronic device in his teeth. At the same time, Dr. Felix recalls that Russell realized something was wrong with him and wanted treatment. He responded so well to anti-psychotic medication that Dr. Felix understands how someone who has never met Russell might be surprised to learn he ever had a problem: 'Quite a few times I would see him and wonder how anything could have been wrong with this person,' Dr. Felix recalls.

But medication alone would not have been the answer for Russell, just as it is not the end-all solution for others like him. A second pitfall threatened to sabotage his progress. 'He had trouble getting approved for Social Security,' Dr. Felix recalls. 'We had to submit new evaluations, but there was still a good amount of following up that had to be done-the kind of task a CTI case worker rou-tinely handles for patients.'

Making sure medications are taken and obtaining Social Security benefits fall respectively into the first two of the program's five areas of intervention: medication management and money management. Medication compliance is closely monitored while men are in the shelter. The likelihood that patients will forget or refuse to take medication increases when they leave the shelter. Paying rent is also a risk because it's a new task in their lives. CTI specialists set up systems for their patients, helping them develop skills to take their medications and pay their rent.

Russell D’Arpa spent years in and out of shelters and on the streets before the CTI program helped him deal with his illness and with his return to the community.
Russell D’Arpa spent years in and out of shelters and on the streets before the CTI program helped him deal with his illness and with his return to the community.

The third area, substance use treatment, addresses a patient's potential to revert to past addictions. Patients who abuse drugs are at a greater risk of falling down in the first two categories. While under the influence patients may refuse or forget to take medication for their illness, and income reserved for rent may be spent on alcohol or drugs. The CTI program assists and encourages patients to enroll in long-term substance abuse programs that will extend beyond the nine-month follow-up period. In addition, more emphasis is placed on budget practices. Patients are encouraged to pay the rent first, before using income for anything else.

Luckily, Russell has had no problem with substance use or addiction, but many other problems could crop up and jeopardize his housing. That is why the fourth CTI category, crisis management, is important to all program participants.

'There is no cure for schizophrenia,' explains Dr. Felix. 'There are only medications to control symptoms. Russell is fairly symptom-free, but he still relies on his meds.' At any time, any CTI patient could stop taking medication, lose financial support, or experience an unforeseen problem. The program develops a crisis plan for the patient in case of such an emergency and teaches the patient skills to prevent or manage crises. Key to this plan is encouraging the patient to reach out for assistance in times of trouble. Family members can be helpful in this category, which brings to light the importance of the next category.

Family support is the final piece of the program. The families of CTI patients are educated on the nature of mental illness. Not only do they gain a better understanding of what their loved ones endured and still struggle with, they also are trained to respond to future crises. Had this education been available 15 years ago, Russell and his father might not have had a falling out.

The success of the CTI program has made it a model for other institutions. According to Dr. Felix, the Veterans Administration is using a version of this system, Rockland Psychiatric Center has piloted a version, and even other countries are following CTI's lead in adopting the idea of continuous follow-up care.

Dr. Felix sees that the next challenge resides within the prison system. Those who were incarcerated because of actions related to mental illness have a special need for intervention as they return to the community. Dr. Felix also envisions the program changing to include vocational training.

When asked if the program is lacking anything, his answer comes without hesitation: 'More housing,' he says. 'There is a big effort right now in Albany to get more housing. That would benefit the men in our program greatly.'

Although some homeless men have mental illnesses that are too severe to be helped by the CTI program, Russell's case is not uncommon. When he speaks of his illness, it is hard to believe he suffers from anything other than the visible side effects from his medications-a tightness in his jaw and neck and a slight slur in his speech. He is soft-spoken, polite, very friendly, and very open. But the 46-year-old realizes that he still suffers from a serious illness and must continue to take his medication. He doesn't know if the voices would return were he to stop, but he doesn't want to take any chances.

He has his own room at the Independence House on 167th Street. He has decorated it with several pictures of his nieces and nephews. He has many friends in the building and enjoys living in the area. A picture of himself with his family at his brother's wedding sits on a shelf next to his medications. His face lights up when he looks at it. He sees his family on weekends and once a year when he vacations with them in Florida. They now understand that Russell suffers from an illness, and they know how to respond should he relapse. He and his father have repaired their relationship. 'My father and I get along great now,' he says with a smile. 'Thank God for this program.'

Nine Critical Months

The five areas of intervention are vital to CTI's success. Equally important is how they are implemented. Although Dr. Felix explains that this program is still evolving, the initial implementation outline breaks the nine-month sequence into four stages.

The first stage is support and assessment. During the first two months after the patient leaves the shelter and enters the community, an outlined treatment plan is established addressing the patient's short- and long-term issues. Part of this phase includes establishing what support will come from the CTI worker and what support will come from community resources or family members. This can be a challenging time for the patient as he acclimates to life outside of the shelter. Often a case worker will accompany patients to their first encounters with representatives from their new housing, because the individual may have difficulty interacting with new faces and surroundings.

The next stage is negotiation. Whatever systems have been put in place for the patient may need adjusting. The CTI specialist reacts accordingly to fine-tune the treatment and address any new issues the individual may have. This stage should last two months, which means that four months after the person has left the shelter, any conflicts in his treatment should be rectified.

The third stage is monitoring. The patient's treatment is evaluated to ensure no problems persist and that any issue addressed during negotiation has not resurfaced. At this point, the CTI worker is becoming less involved. This stage should last about three months, allowing enough time for any last negotiations.

The last two months in the program involve the final stage, which is transfer of care. During this period, the CTI worker meets with the patient every two weeks to prepare him for termination of the CTI program. Any remaining problems or negative feelings the patient may be experiencing-especially in regard to exiting the program-are addressed during this final phase.

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