Experts on Homelessness Provide Insight at CAG’s September Meeting

The Georgetown Ministry Center (GMC) provided a fascinating program for CAG at Grace Episcopal Church on September 27, 2012. Gunther Stern, Executive Director of the Georgetown Ministry Center, welcomed the group and outlined the services the GMC provides for the homeless in Georgetown.  He introduced Dr. Ron Koshes who talked about the central relationship between mental illness and homelessness.  Legal expert Brian Stettin, the Policy Director of the Treatment Advocacy Center, explained the evolving laws surrounding mental illness and homelessness over the past half-century. The Ministry Center showed two illuminating videos featuring poignant stories from homeless individuals and their families. Below is a full transcript of the meeting with interesting questions from the audience at the conclusion of the meeting or you can download a PDF of the transcript here.

CAG Meeting on Homelessness in Georgetown (transcript)
Sept 27, 2012 at Grace Church

Jennifer Altemus:  Thank you, thanks for having us. Hi, I'm Jennifer Altemus. I'm the President of the Citizens Association of Georgetown. I want to thank Grace Church and Georgetown Ministries for hosting us. Thanks to Wisey's for the refreshments.
I want to introduce our host for this evening, Dr. Gunther Stern, the executive director of Georgetown Ministry Center. He has been working with the homeless for the last 25 years. He started at Temperance Table in Silver Spring and has been in Georgetown for the past 22 years. He splits his time between case management, program development, and staff supervision and training. He is particularly skilled at counseling and aiding people suffering with mental illness and substance abuse issues. I am grateful to him and to our panel for the wonderful work that they do here in our community and for this chance tonight to see more specifically how they do this.
Gunther:   Thank you for the opportunity to talk to you. We have a lot to tell you, and we hope to be fast for you. I'd like it if we could hold questions until the end and then we'll be glad to answer your questions. Speaking tonight will be Dr. Ronald Koshes who is sitting next to me. He's worked with GMC for over 15 years and knows people on the street and in our office. We call him Dr. Ron. Also, Brian Stettin from Treatment Advocacy Center, a national advocacy organization for better sustained treatment for people with mental illness.
I have, as it turns out, made a career out of homelessness. It's not anything I've intended. I've often said that I'd rather put myself out of work. Sadly, this is not the case. The ministry opened its doors here at Grace Church 25 years ago this fall. This is our 25th anniversary.
We have grown in many ways from the original small outpost which you see right up in the stairway that you came up. When we opened the doors in 1987, the bathroom was off limits to our guests. Most of what we did was outreach. We are now huge by comparison. We're still very small compared to a lot of organizations. We have three bathrooms which are all used quite a lot. There are often people hopping around in front of the doors waiting for them to become open, including staff. We can accommodate 20 showers a day, five laundries a day, and you could easily double that capacity. We have one washer, one dryer, one shower, so we just don't have the space for it, the capacity.
Eight years ago, the city envisioned a plan to end homelessness in 10 years. This is year eight, and I see as many homeless people on the street as I did year one. There is no change. In fact, there's evidence that homelessness on our streets is growing.
I want to introduce the staff. I'll start with the person closest to me, Jessica Fitzgerald.
Jessica Fitzgerald:   Hi, I'm Jessica Fitzgerald. I'm the current intern/event coordinator. You might have noticed some of the reading materials on the pew in the back, and we have some invitations for the Spirit of Georgetown party. If you're not familiar with the Spirit, it's a night of glitz and glamour and drinks, and it's a good time. It's one of our biggest fundraisers, so please feel free to pick up an invitation. Next to that is our newsletter and information on some events that we have coming up, as well as donation items that we could really use, and ways to volunteer.
We also have a friend in the house, Woodley House. They, among many other things, provide housing for the mentally ill in the DC community. Please pick up one of their handouts as well. I'll turn it over to my coworker, Stephanie Chan, who will talk of the club house that we have here at Georgetown.
Stephanie Chan:  Hello, everybody. My name is Stephanie Chan. I'm program manager at Georgetown Ministry Center. Georgetown Ministry Center is a very special place. Everyone who comes into our center is either a guest or a member, which is what a lot of other organizations call people who could come in and use their services. We try to treat everyone that comes to the center with dignity and respect. We try to give them a lot of say in what happens in the center. Every Tuesday, for example, we have something called a house meeting. It's a time when staff and all of our guests get together and they can raise concerns or suggestions that they have about what we can be doing better in the center and what people like to see in the center.
We encourage everyone that comes to the center to take time and share. We encourage everyone to help us create and help set the tone of the center. I always tell them if they want to come to a safe and respectful place that they're responsible for doing that, and they do.
[applause]
Gunther:  She won't talk, but Diamond Sasser is our business manager. Roy, who just walked in, does a lot of the case management. This past month three people went into housing. I guess one is still on the edge but just about to go in. We're real proud of that. I really want the speakers to have most of the time because they're really great speakers. Over the years, what I've learned is that we're not going to solve homelessness until we really address, at least for the people who are chronically on the street, the major mental illness that causes a lot of the homelessness.
For everyone tonight, I asked Ron and Brian to come and talk. We have a video. Are we ready to show the video? Let's show that, and then we'll let Ron talk and then Brian.
Music and VIDEO narrative:
In 2006, Greg Sherman passed away. His family found out in 2010.
Daughter:  My dad, Greg Sherman, was homeless, but his life didn't start on the streets. But, sadly, it ended there. He was a beautifully bright baby, so I'm told, kind of a prodigy in lots of ways. He was the golden child of our family. He met my mom in prelaw at Northwestern. He was a very clouded man, always struggling.
Son:  I think he was a good man who just got lost. He would be the life of the party. He would be so much fun to be around, very witty, sharp, intelligent. Then something switched inside of him. My parents divorced. I didn't know at the time how much he was actually struggling with. It wasn't just alcoholism. It wasn't just depression. There was something deep seated in his mind that was affecting his entire life, and it affected our family.
Daughter:  By the time I got to high school, I could tell that there was a shift. He had gone off the medications that were stabilizing him. He went all the way around the world. We don't really know much. Finally, he ended up in Los Angeles where my brother was going to school at USC.
Son:  For those of you who don't know, there's a large homeless population in Santa Monica by the beach. I spent the last year being a part of a ministry that was reaching out to these people, and now one of these people was my father. He didn't stay in Los Angeles very long, but he was always in contact with my sister and I.
Daughter:  When I was a junior in college, I skipped class Thanksgiving week, and my dad called. That was the last time I heard my dad's voice. I'm really happy that I skipped class that day. The family tried lots of different tactics trying to find my father, but we had no idea where he was. It got really painful. By the time it had been almost seven years, I thought, "This is ridiculous" and I wrote a letter to Social Security saying that I'm the daughter, I'm concerned about his welfare. My husband took me the post office, and I opened the letter. All there was, was a form letter saying that he had died. Nobody in the family knew. He'd been dead for years and nobody knew.
My brother took it upon himself, God bless him, to just do a lot of research. He found out the medical records and through finding all the history, where Dad was buried, and all these different things. We found out he was in D.C. We found out about Gunther, because Gunther actually ID'd the body. He knew Dad and had come in contact with him.
What was so wonderful...Gunther knew my father, and that's a wonderful thing to know, that someone knew him when we couldn't be there for him.
Son:  It was his choice to disconnect from the family, but due to his mental state, I'm not sure how much of his choice it was.
Daughter:  It's so difficult right now. People's hands are so tied to help the people we love with mental illness, with this legislation that hasn't passed and legislation that will not be passed.
Son:  I would never consider myself a political activist, but this is not just some random homeless person that you may have encountered, this was my father.
[music concluding video.}
Ron Koshes:  I'm Dr. Ron Koshes. I'm a psychiatrist here in Washington. My work with Georgetown Ministry Center started after I started working for D.C. government and found out the real important issues. We were making connections with people on the street who had severe and chronic mental illness. I think the most important thing you've heard tonight is what Greg's son has said, that it may have been a choice when disconnecting from the family, but not really his own choice. I want to spend just a minute talking with you about the sociological underlying homelessness, mental illness, some exciting things that we understand about the brain, and why our work in outreach in the community is so important.
First of all, in the late 1950s a horse tranquilizer was discovered in Scotland, and it was tried on prisoners, of course. They were found to be amazingly calm when administered. It came to the United States marketed under the name of Thorazine, or Chlorpromazine. This switch at the beginning of the 1960s, and one of the last things that John F. Kennedy did was he said that since we have these new medicines being developed, we can create community mental health centers in all of our major cities and all of our towns so that we can get people out of the asylum from behind stone walls and locked gates, out in the community where they can do well and prosper.
They can have an opportunity to have a regular life. It was a wonderful idea. Unfortunately, the technology was not correct at that time. These medicines were pretty toxic. They caused movement disorders, dry mouth, constipation, blurred vision, and slow thinking especially.
People, as they stopped their medicines, began to feel better. What I'm telling you is why in Georgetown and why in other streets in Washington, we have a huge number of homeless people. It's because institutions no longer keep these people. They throw them out to the street, and they are very suspicious of mental health professionals providing them treatment because it doesn't feel good in many cases.
Now, fast forward to the 1990s when we began to have new vision techniques in the brain and new understanding of what causes the major mental illnesses such as schizophrenia and bipolar disorder. We know a lot about these. We are just catching up with the technology and pharmaceuticals in order to help these folks.
What appears to be the case is that deep centers in the brain that are responsible for integrating the interpretation of reality are disconnected from the frontal lobe of the brain which is our executive function. Basically, you and I see the light flickering. We say it's a bad bulb because what we're doing is we're using our logic, we're using our powers of observation. We're not getting too excited by it. We're able to calm down. Let's get a ladder and get it done.
Someone with a mental illness may see the same thing we do and misinterpret it, that it's an electrical charge from an alien ship in the sky and they can have all sorts of fun coming up with stories.
Now, we understand that those brain pathways are the ones that are dysfunctional, and there are certain medicines that have been developed and are being developed which directly address the problem.
There are fits and starts in drug development of course, but the basic thing is that many of these medicines are easier to take, they're more tolerable. People don't feel medicated, and they don't look like they're medicated. We try to bring the newest medicines to people who are living on the streets because they've had such bad experiences in the past.
Now what is the problem? The problem is before someone suffers an acute psychotic break, the disease process is already pretty advanced. Let me give you an example from general medicine.
A person who has heart disease doesn't begin to have heart disease with their first heart attack. They have a number of physical abnormalities and the heart attack, the myocardial infarction, is the signal event that alerts physicians that there's a problem. Then you go onto treatment.
We know that early on in adolescence these parts of the brain that were connected -- that I was talking to you about -- begin to lose connection. The neurons in the brain begin to lose the sheets that cover and nourish the cells and tissue.
This gradually, gradually occurs driven by hormones, driven by stress, driven by substance abuse. Then the person has this psychotic break. The disease process is already well advanced by the time they ever reach any physician.
There's a lot of distrust in someone going to a physician because their reality is their version of reality. And so, part of the work we do is to try and reach people on the street and to give them a different sense of reality, give them different alternatives without really challenging their basic assumptions.
This can take, sometimes, six months, eight months. With some of the people we've worked with, it's taken three to four years to get results. We're still not doing it quickly enough. We still don't have the manpower to do it. The government of the District of Columbia is committed to helping the homeless, but they just don't have personnel to be able to do the comprehensive job that they need to do.
And so, across America and, of course, here in Georgetown, our community oriented groups are going out identifying people trying to make contact, trying to get them into a system where they can be appropriately medicated, and get housing, and something to eat during the day. Now I'm going to let Brian talk… or take a few questions?
Gunther:  No. Why don't we put them at the end? If that’s OK?
Brian Stettin:  I'll introduce myself. Thanks. Let me just say in my career I've gone to a lot of community meetings all over the country, and I've got to tell you, I've never been to one where the refreshments were so good. [laughter]  
But on a more serious vein, as Gunther said, I'm Brian Stettin. I'm the policy director for a nonprofit based here -- actually in Arlington -- called the Treatment Advocacy Center. We work around the country to change mental health laws to make it easier to get folks -- like the gentleman who was in the video you just saw -- into treatment when they don't necessarily understand that they have a need for treatment. The video actually dovetails very nicely with what I want to open with tonight, because I have to tell you before I even got involved in this issue professionally, if you had asked me about the typical homeless person, to be honest with you, I probably (it's not that I wouldn't have been compassionate about homelessness) but my assumption probably would have been that most of the people you see out there came from extremely disadvantaged backgrounds, never really had a chance in life, and so when things went wrong for them, things went off the rails. I guess I would have said they have wound up in that situation… I probably would have guessed that many of them did not really have anyone out in the world caring about them. Because if they did, why wouldn't they swoop in and rescue them from that situation as we all probably imagine we would do if we had a loved one in that boat? But I can say I've been pretty thoroughly disabused with that notion from the work that I've done.
But what I've really come to know is that what we saw in the film is actually quite common. Many of the people who we see on the street have people who love them. Many of them come from very stable families, sometimes even from affluent families. I get calls from people every day who lie awake at night worrying about a loved one of theirs who is homeless. Why don't they come in and save them? Well, the answer is they can't, and the reason they can't is because...well, there are lots of reasons. I don't want to oversimplify them, but a huge part of it is that the law is not on their side. Before I explain statistically why it is, let me just give a little bit of historical context.
In the early 20th century, this nation was really dotted with state psychiatric hospitals. There were these kinds of gothic castles usually in remote parts of the state, beautiful grounds that were very large where people got sent when they started to exhibit signs of mental illness, and it was not terribly hard to get people sent there, often for a very long time.
There was, of course, a court process where you had to be committed, but the laws were really written to give great deference to the opinions of the doctors. The laws basically said in most states that the commitment was “in the person's best interest.” However, the doctors defined what was good enough. It was really a very easy process to get people into that kind of long-term care, and often people would spend their entire lives in it.
Lest anybody think I'm waxing nostalgic for this era, that happened long before I was born, I want to be clear. I'm not. I'm not suggesting that those were the good old days by any means.
The fact is, in that era I'm talking about the early part of the 20th century up to about the late '50s it was extremely easy to get people hospitalized for being a little different. There was no consideration given to whether there were less restrictive alternatives that could serve people's needs in less restrictive environments, and lord knows, there were abuses that went on in those hospitals.
The fact that there was a need for a change I think is indisputable. What happened in the 1960s is you had a movement called the deinstitutionalization movement. This was, of course, in the wake of the civil rights movement for racial justice which unleashed lots of other movements where people started to look around and think about how this society would be more just. And so, you had, obviously, the women's movement that grew out of that, and the gay rights movement.
In that same vein, came this movement to achieve some justice for people who had been locked away in these hospitals. In that era of deinstitutionalization, a lot of these hospitals were shut down, downsized, and laws were rewritten. Certainly the commitment law that we have here in D.C. is very emblematic of that.
I think around 1970 Congress wrote new commitment code for the District called the Urban Act. It basically says that the mentally ill individual's right to freedom to be outside of the hospital and live their life as they see fit, can only be overwritten under circumstances where there's this compelling government interest to prevent a danger to that individual or to somebody else.
Specifically, I'll read a sentence to you from the law it says, "If the courts or jury finds the person is mentally ill, and because of that mental illness is likely to injure himself or others if not committed, the court may order the person's commitment." On the surface, it's not an unreasonable approach if interpreted reasonably. But here's the rub.
This turned out to be a very rare area where this sort of liberal well-intentioned concern for people's civil rights fed into the determination of people on the other side of the political spectrum, people who are fiscally conservative, to spend less on social services, and so the fact is, why do you need more hospitals? It's expensive, more expensive than putting it in your community, especially when you're not putting all kinds of community service in there to counteract what you've done to the hospitals.
This liberal deal to get people out of hospitals was coupled with the fact that in the states where conservatives had more power, they were thrilled about this because it was a way to cut social service budgets without having to generate a whole lot of controversy.
There was no real check on this movement, and it took on a life of its own. I think it's fair to say the pendulum swung way too far to the point today, just to put it in context: in 1955, you had basically, about 340 state hospital beds for every 100,000 population in this country. Today, we have 22.
Now, again, no one would deny that 340 per 100,000 is probably too many, but the idea that as a population of the country has exploded the number of beds has plummeted and left us with that kind of discrepancy, is pretty hard to justify.
Of course, there's another problem which is that this civil rights movement came to be influenced by a very radical anti-psychiatry movement which questioned whether there really was such a thing as mental illness as a medical disease, or whether this was just maybe a social construct that was created to put people in their place who questioned authority.
It sounds absurd, but these ideas took on a lot of cachet, and so what we came to have is a mental health system that was very influenced by all of these factors. These were influenced not just by the laws themselves, which as I already said is not entirely unreasonable, but more importantly the way these laws were interpreted.
The legacy of that is on vivid display in D.C. today, there's no doubting the fact that there are people walking the streets who compassion would dictate ought not be there. If you think it's bad on the streets, you should see what's happening to our jails and prisons which have become our new institutions, but that's a discussion for another night.
The problem if we really get specific about it was the way this requirement of finding serious injury was interpreted. It's been widely interpreted, certainly in D.C. and elsewhere or wherever they have similar laws, to mean that there has to be proof of an imminent risk of violence or suicide. The person has to be acting in a violent way or threatening some violent act to meet this standard that says that it’s proof of serious injury.
Well, of course, when you take a step back and think about it, injury doesn't necessarily mean that. There are lots of ways to injure yourself rather than intentionally doing so, and if you stop to consider the irony. I mean where's the compassion in interpreting the laws so narrowly?
This was all supposed to be about civil rights and about respecting the dignity of the individual, and so what we're doing is we're allowing people basically to die with their rights on. We've got where folks out there who are too sick to even understand they have a need for shelter, and we're letting them roam in this state of terror, racked by these horrifying delusions, all because we're letting them self direct their own care.
What has been forgotten here is the fact that this is not like other types of illness. This is not like letting a cancer patient make an important decision about whether they're going to have chemotherapy or not. We're talking here about diseases that interfere with the brain, with one's ability to make rational decisions.
To me, it seems like common sense that the compassionate thing to do is not to leave the decision in that person's hand because these aren't decisions they would ever make in their right mind. I think the film very vividly displays that.
What is the solution? The solution, one big piece of it, is to fix the laws. On one hand, because the law itself is really not the problem so much as the way it's been interpreted, it almost shouldn't be necessary. The fact that there have been various times when people have tried to use the D.C. law to commit people who are not actively trying to hurt anyone, acting out violently or suicidally. The courts have agreed several times that the injury means something broader than that.
There was a case in 1987 of a woman who believed that food was hurting her, that medication and food were actually harming her and killing her. She would not accept food or medication when she was out of the hospital, and doctors made the case that they did not want to release her because she was going to injure herself not by trying to hurt herself, in fact, she was trying to do the opposite.
She was trying to protect herself by not eating. But this is a form of injury one does to oneself, and the court, of course, agreed that that made sense. We have this case law that says that the law is not as narrow as everyone seems to read it.
Yet somehow the message doesn't seem to get through. We still have this very common situation where some loved one calls the police officer, calls the police department and are told, "Well, is he trying to hurt anybody? Is he threatening to hurt himself, kill himself? We can't do anything. Call us back when he does."
What's really desperately needed is to make it explicit in the law that injury to self means something more than that. There are basically two levels further that the law really should go, that a lot of states have accomplished to great effect.
One is to get an alternative definition of “injury to self” which is what was going on in that case I talked about a minute ago, the idea that failure to meet one's own basic needs for food, clothing, shelter, is a form of injury to oneself. The law should state that specifically.
Even beyond that, when we talk about danger to one's self, it shouldn't necessarily even be mortal danger. Just the fact that a person is suffering profoundly as a result of this mental illness, in my mind, that's a harm in itself.
The danger that that's going to happen is one that we as a compassionate society ought to want to address, so the law could also, and in many states do today, say explicitly that a person who is suffering from their mental illness and is in no position to do anything about it themselves because of their lack of insight is also someone who is at risk of injury and in need of involuntary care.
This is just a basic overview of what I would like to see happen to the DC Commitment Program. I thank you very much for listening, and I hope these changes are something that you all will support. Thanks again.
[applause]
Gunther: We have another video. We have two families who very bravely told their stories for us:
VIDEO narrative:
Woman 1:  If he were in a program, or if he were back in a situation-even if I lived on Main Street, he'd be out there talking to everyone, saying, "Hi, how are you?" I mean, he doesn't get that here. But it's amazing. You go into a restaurant with him, and all the waiters and waitresses love him. They're like, "He's so friendly and so happy that he's there, that it's contagious."
We used to drop him back off at Turning Point sometimes, mom and I, or I would, and there would be guys waiting on the porch for Tom to come home. And that gives him a sense of ego, which he needs, because everybody likes him so much. Of course, he got the nickname "Cigarette Man" at Turning Point, because he gives away all his cigarettes but, everybody waits for Tom.
[on screen] Tom Bockoven has been homeless for over 25 years
Man 4:  Yeah. [music]
Man 5:  I still think...DC is a more...is a less policed town than most cosmopolitan areas. They will actively do something about homeless people in most cosmopolitan areas. In Washington it's a little more laid back at least that's what I think.
Woman 1:  You mean, like, are you comparing it to Hagerstown-were they a little more...?
Man 5:  No, I'm talking about New York City, or Boston or California.
Man 4:  You've been to all those places?
Man 5:  Yes, I have. [music]
Tom has traveled thousands of miles across the United States and Canada on foot.
Woman 4:  I still- really just for 36 hours he never stopped.
Man 6:  So he's driving?
Woman 4:  Yeah. He drove the whole time he only stopped for gas, and I found one receipt that he had gone through a turnpike. I think he just breezed through, because he never handed his card back in. But he really came back, thinking well, you know, my compass was broken. He has one in his car. One thing is when they first started medicating dad, it was sad because he should have had some medication prior to this because if he himself had manic depression and it was never treated in those days or dealt with in those days very well-and it would have helped him if he had had it earlier. So he had the combination of that and the Alzheimer's.
[music]
Tom's family has a history of mental illness, including Manic Depression. He was diagnosed with paranoid schizophrenia when he was in his early 20s.
Man 7:  I began to notice because was I was in with college people because they were more educated, they were more aware. They, um, I began to notice that I was schizophrenic and I began to feel that I was schizophrenic that I couldn't apply myself- that I lost some concentration and I didn't learn real good. But I began to feel like--It's standard, it happens to men in their 20s and that's when it happened to me.
Woman 5:  I didn't understand what was wrong - Tom wouldn't talk. He was loving, kind, sat in my apartment, really couldn't talk. There was nothing verbal. And so I was terrified because I knew nothing about these diseases, even my father's illness we didn't become aware of until we were older--when we would put the pieces together about his illness. So I really didn't know. I never understood my father when he would talk to me, always very high intellect to, very high intellect. A lot of this I didn't come to terms with until I was about 25 and pieced it all together.
Tom was-there was nothing wrong with Tom, in terms of...He was as docile as could be, but he wouldn't talk and I was scared I don't know why he wasn't talking.
[on screen] With he help and guidance of places like Turning Point and The Georgetown Ministry Center Tom began to find connections - to his community as well as his family.
Man 8:  You studied guitar, though, before...you're a pretty great guitar player?
Tom:  No, I'm not. I'm an amateur, and let me tell you, I ran into, I said, my counselor said "we're going to discharge you from Turning Point and you're going to go to the Mission." And I said Oh God what a pit. Well I ran into a guitar player there who played his ass off. And he was what, 18? And I felt like a real clod.
Tom:  [begins playing the guitar] I'm scared, Ok. [music]
[video ends]
Gunther:   When I met Tom, it was 25 years ago. I came here following Tom. When I met him, he had been living in the woods. He was filthy. He couldn't say two sentences. For 10 years, he lived like that. At some point, he and Ron and I started talking. Over a period of about a year, we introduced medication. He took medication for three days, and then he'd disappear for a few weeks. Then he took it for one day and disappeared. Eventually, he started taking it, and eventually, we got him into placement.
He didn't get better all at once. About two years after he started taking the medicine, he was in a program out in Montgomery County. I called him one day, and he said, "Gunther, how the hell are you?" It was just amazing. It was a different Tom. This is the Tom you see now.
One of the things that Ron will probably tell you, the sooner you introduce medication to somebody, the more brain they're going to have left. Every year that they don't have medication they're losing brain cells.
Ron: We can't quantify that, but, in fact, it's true. The longer a person is psychotic, the longer it takes them to recover normal functioning, and they recover it at a lower level. The idea is to get to them before they have severe symptoms.
In fact, do you remember the example I was giving you about cardiac illness? We really don't tell our patients, "You're fat. You don't exercise. You're under a lot of stress. When you have your heart attack, come to me and we'll do something about it." There are certain warning signs that we have, and these are being documented in population studies all over the world, early warnings signs of schizophrenia and bipolar disorder and other major psychiatric illnesses that we need to get to intervene early before the major changes that occur in the brain begin.
Brian: I'd just like to say one last thing. I'd like you to, when you get a chance, look at the treatment advocacy center's website because there is so much good information there.
Ron:  I've got some newsletters, too.
Brian:  I just think it's one of my best resources in terms of understanding mental illness and homeless and how they relate. I definitely recommend that website. Give us some good questions now. We've taken too long already.
Woman 1:  A couple of years back you got a lady who was at the corner of Wisconsin and M Street in rehab. I was curious under what guise...how did you manage that?
Gunther:  There was woman that was at Wisconsin and M Street and...
Ron:  Exactly. We'd known her for years and years and years, but it seems that this woman also knew commitment laws. She would be very careful not to indicate that she was a risk to herself or others even though it was clear that she was not taking care of herself. She was severely mentally ill. She was headed down the wrong path. One winter day, we asked her if she wanted a blanket, and she said, "I don't need one. The CIA has implanted heating chips in my body." I looked at Gunther. He looked at me, and we said, "Yes."
She was suffering from mental illness. She was a risk to herself or others because it was below freezing and as a result of that mental illness was in imminent danger. We were able to commit her. She was so mad at us because she wasn't able to say no. She was very grateful for being committed and getting back on the right drug.
This is the one thing that Brian, I think, said that we had to remember. These are illnesses that affect our ability to have judgment, reasoning, and insight. The laws have to be flexible enough so that we can get a person into treatment and then they can make a rational decision.
There are models to this in medicine. Someone who is uremic, they have kidney failure, and they say, "I do not want to be dialyzed" the law supports physicians dialyzing that person to bring them back to a normal state of functioning where they can begin to have the dialog with their doctor.
Gunther:  I'd just like to say one more thing on that. I talked with that woman two days after she was in the hospital, and she said, "I'm so mad at you, but I'm so glad you did this. I can't believe how bad it was." She was much clearer just two days after.
Man 2:  Well, we've been focusing almost all on medication and treatment, but is it also a lot of assistance and improvement just like having a place where people can go get showers, go the bathroom, do their laundry, get lessons, eat sandwiches, and all that kind of stuff like we have right here? Does that also contribute to improvement or not?
Gunther:  I think what that does is keep people safe and reduces harm. It may add something to their lives.  I don't think that's going to solve the real underlying problem. I think what we need is...
Man 2:  But does it help? It may not be the solution, but is there some improvement with assistance?
Gunther:  Let me just say that I think what we do is so important. I mean, just letting 20 people take showers every day is huge. It also brings them into a place where we keep widening the connection and we try to bring them to the next step. It may be a little bit therapeutic, but it's not going to solve the real problem. Putting more doctors on the street is not the answer, so places like Georgetown Ministry Center and other drop-in centers are vital for engaging people and to move them towards the next step.
Homelessness is a long cycle. It took Tom many, many years to drop out of society. It took him a good amount of time to get back in too. I would say about two years. Interesting story about being beautifully managed on medication, went to a different agency and didn't want to spend the time getting prior authorization...
Ron:  Anyway, Tom was placed on a different medication which we didn't know about. He started to decompensate in one of the programs he was in, in Maryland, and his sister was smart enough, she brought him back down to us. This was just in the last six months. We got him back on his meds, and he's doing fine again.
Man 2:  And he went off seven meds.
Ron:  Yeah. I took him off seven medications.
Woman 1:  Ron, are you suggesting that there's a feeling now that there are warning signs and symptoms? I'd like hear a little bit about that and actually also give us some guidance as to what to do when you see a homeless person on the street. I tend to delay having the conversation. Sometimes the conversation doesn't make any sense at all. I'm a little bit at a loss after that as to what to do.
Ron:  There were two questions. One was what are some of the signs and symptoms of mental illness. In New Zealand where all the psychiatrists know each other, I've been a couple of times, they do tremendous studies of mental illness over the course of years. You guys, don't take this the wrong way because you'll be examining all your children and grandchildren, but one of the first, earliest confirmed signs that they found in the development of schizophrenia is teenage substance abuse.
It may be an attempt for the person to try and self medicate. That does not mean that everyone who has a couple of beers and becomes a little drunk is going to be schizophrenic, but it is one of the earliest signs.
What this does is it helps doctors and social workers begin to think ….. when someone comes in with substance abuse during those years and their differential is a major mental illness. It's just one of the things that you have to look for.
You also look for family history. You also look for sibling history, mother, father, grandparents. Again, substance abuse, criminal behavior. If a person has been doing well and then begins to drop off the developmental track.
They're the life of the party. They're on the football team. They're in the band. Then they start to withdraw, stay in their room, hygiene goes down. Those are all symptoms that a physician really needs to see and the family needs to be monitoring that person better.
How do we engage people on the street? You say hello first. Doug and I are really quick about trying to [inaudible ] walks around and we're done and if you need anything let us know. It's face recognition, name recognition. We invite them to the shelter. We try little by little to get them to connect to other human beings, especially the most severe.
That's number one. Number two, always in the back of our mind is looking for the ability to involuntarily hospitalize them if they're dangerous. We've done that many times.
Man 2:  You've been talking a lot about mental illness/illnesses. Is there really a one to one correlation? What's the correlation that you think actually exists?
Ron:  I think the estimate I've seen is something about 40 to 45 percent of chronically homeless people have severe mental illness.
But I also think it's higher here because we have the major psychotic institutions of the world the Pentagon, the CIA, the FBI. [laughter]
 People come from all over the world and all over the country to make their peace with the government. I think we're a little bit higher, Brian, don't you?
Brian:  That would make sense to me.
Ron:  Yeah, the question was, "What was the medication?" He has been on several medications, and we've put him on more. Well, no, but you're close. It's a combination drug of Fluoxetine and Olanzapine called Symbyax.
Woman 1:  Sy...
Ron:  Symbyax. It's an antidepressant and antipsychotic agent. One of the things that people don't understand, if you look at it, it's not just psychotic illness that these folks are suffering from. There's a lot of anxiety. We had a guy who we got down from Loblaw Park. He's now in housing, and he's doing great. He was suffering from severe panic attacks. He began using alcohol to take care of himself. He became homeless, lost his job, and just went through behind a dumpster. His treatment was not an antipsychotic, but an antidepressant.
Woman 1:  I presume that it also goes hand in hand with some counseling, along with the medication?
Ron:  We don't talk to our patients. [laughs] Yes, of course, absolutely.
Woman 1:  To come to some conclusion about how mentally ill they are, and the dosage, and that kind of thing.
Ron:  Yes, counseling is very important. I consider work on the street with severely chronic mentally ill people is that you really have to get them under control. Then you can begin the important work of exploring their life, and such and such. A lecture about seatbelts is not given to the person in the car accident.
Woman 1:  This follows up with that. Why shouldn't you work so quickly that they can see that this is the beginning of a path and have you pierce their paranoia. Tom, you gave them medication for a couple of days, then disappear. How can they feel the effects of it?
Ron:  The question is how do you get someone better quickly and...
Woman 1:  And pierce the paranoia.
Ron:  And pierce the paranoia.
Woman 1:  So that when they say no, no no, no.
Ron:  You don't really argue with someone who believes that their life is in danger because they have a very important secret that the government wants to get. You just can't argue with them. The idea is to make them a little less anxious, and sometimes that takes fits and starts. As a person gets clearer, they also come to the realization that they've been living on the streets and that their life has been pretty much destroyed, something called a post psychotic depression, which happens to a lot of people. That's why it's important to be with someone and monitor them, and help them along.
A lady wanted to believe that the Jehovah's Witnesses were burying people in her backyard, and so she would stay up all night to try and catch them. What she was really describing were moles. You know how moles make the tunnel and everything? She's fine now. She's working again. The Jehovah's Witnesses are still burying people in the backyard, but she doesn't worry about it as much, and she's able to sleep.
Woman 1:  I think you mentioned earlier that 40 to 45 percent of homeless people are mentally ill.
Brian:  That's a national estimate, though, I'm not actually...yeah.
Woman 1:  A national estimate? Do you guys have a proposed solution to help the 55 to 60 percent of homeless people who aren't mentally ill? [crosstalk]
Woman 3:  What was the question?
Brian:  She asked me whether I had a proposed solution for the 55 to 60 percent of homeless individuals who are not severely mentally ill. I would say that's not within the purview of my organization's mission. We're really dealing with severe mental illness and its consequences. I would imagine just off the cuff that substance abuse treatment has a whole lot to do with why a lot of those other folks are on the street, but it's not something I'm going to delve into, because it's outside my expertise. Yes, ma'am?
Woman 4:  When you talk about going to the hospital, how long will they get them? Just the 72 hours, or are you able to get them longer? That's normally a very short time.
Brian:  72 hours is the longest they can keep them if they don't want treatment.  That's for an evaluation.
Ron:  Brian can go through the specific executive for long, something like torturous process, because the idea is you don't want to take anyone's rights away. Unfortunately, I think the thing that you didn't mention, but I believe, is that the laws really have not been informed by medical science, which is up to date now. I mean, there's a lot more that we know about leaving someone to suffer with a serious illness. How long a person stays in the hospital depends on a number of different things. The first is the strength of the admitting physician's record keeping, the person who makes the FD12 which is the involuntary commitment paper, how strong that is and how sick the person is, for sure.
If someone is running butt naked through the streets of Georgetown and it's 16 degrees out, you can FD12 them, you can involuntarily commit them, but when it rises above freezing they can leave the hospital because they are not an imminent danger to themselves. It depends on how aggressive the treatment team wants to be.
Man 2:  First, I want to thank you all for the fabulous job that you're doing here. I'm trying to reconcile for myself a little tension that I see in the conversation when it comes to strengthening the commitment laws or making it easier to get people where they need to be or promising we can get them the medication earlier. But as I go around the city in Franklin Park, 18th and Pennsylvania, or this organization, aren't those groups kind of giving the homeless a base point where they don't fall down that hole, that they're perceived as needing the kind of help that I think you're suggesting would get them off the streets? I don't want to go on and on, but I spent some time in Johannesburg, I see that as a conundrum in this beautiful capital, the townships around it, the slums around that. They support the slums, double the size of the slums. I guess I see tension between the support that's being offered and the need that Ron and Brian are suggesting to maybe solve the problem. I don't have an answer for it.
Gunther:  I think I get what you're saying, and I would offer up that the dozen or so people in the community that don't come into our place and won't come into our place who are so decompensated in their...I can't even describe their condition. It's just very unpleasant. They're not getting the services they need. We're providing some very basic services. We're also, at the same time, trying to connect people with Ron, with a medical doctor, trying to connect people to services and trying to get people into housing. I tend to look at it more as a little bit of trying to get people close enough that we can start talking about getting social security, getting on the housing list, and those types of things.
Ron:  I'll take a crack at it. I think you make an excellent point, sir. One thing that I would say is that the best commitment laws that I've seen, and certainly the way we recommend states write their commitment laws, actually have a line that gets around that problem. You can easily say in the law "if the person could not survive safely in the community but for the support of others." In other words, the crux of the court's determination is really more about whether this person is in any position to provide for themselves, their own survival needs. If someone is spoon feeding them what they need to survive, that's not going to override that determination.
Brian:  Sir, your observation is pretty good. With very exclusive commitment laws which prevent easy access to mental health care, there is a potential for organizations to be in the home for homeless and supportlessness in the communities. That's why the two of us are up here today. Yes, ma'am?
Woman 2:  I have a comment and a question. There are people in our neighborhood here in Georgetown that have, and I have one specific example, I have a homeless person that I support, Mario Schollers. He does gardening for us. I give him a salary every week. I live at the corner of 30th and Q, and probably a lot of you know him because he's always there. Clothes for the year, and when there was a bad snow storm he stayed with us for a week. I don't think we can continue to do that. We had a bad winter this year. It's a very hard balance. Mario wants to work. He needs to be on medication. He will not go on medication. His brother died from an overdose, and he will not take any medication. He's a college graduate, African American. He's quite charming and will engage your ear off, so you have to have very clear boundaries with Mario.
My husband and I have had this relationship with Mario for about three or four years now. I feel but for the grace of God it could be me. I'm concerned. Winter is coming, and I'm getting concerned about Mario.
He's terrified of the shelters. I'm wondering what kind of facilities that you might have. He seems to be less afraid of going into a church in Georgetown, but we really can't have him stay with us. If you could address that I'd appreciate it.
Gunther:  I know Mario well. I've known him for 22 years, and he knows me. I offer all the time to talk to him about different kinds of solutions. We're here for him. Anyway, we do have a winter shelter, and it is possible to...We have a winter shelter in churches. When it's here at Grace Church, it's in this room. The chairs are pushed apart, and the cots come in.
Woman 1:  Is that on a weekly basis, a daily basis? How does that work?
Gunther:  The 10 people that we take in at the beginning of the winter stay for the winter. We really want 10 people who are going to make a commitment to come and stay for the winter and form a community with the others and the volunteers who support the shelter. He knows that.
Woman 1:  Thank you.
Gunther:  Sure. Anybody else? I'm getting a signal. This is it.  Thank you so much. [applause]

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