the released

Sherri Sullivan

VIDEO EXCERPT

She is the program director at Bridgeview Manor, an adult care home in Ashtabula, Ohio. Bridgeview houses 16 men and provides on-site mental health treatment. This is the edited transcript of an interview conducted on Aug. 20, 2008.

What is Bridgeview Manor, and why was it created?

Bridgeview Manor is a residential treatment facility that was created a little over a year ago by the [North Coast] Center, which is a community mental health agency in Ashtabula County, [Ohio]. And essentially, it was created because we have a population of chronically, severely mentally ill people that don't have anyplace to live, particularly when they're coming out of the state mental hospitals.

Why don't you have anyplace for them to live?

... There is no place for clients to live because they really don't have finances; they don't have stable housing histories; there are very limited opportunities for low-income housing in Ashtabula County; and most of our clients are ineligible because of perhaps criminal histories, incarceration and other issues that may have come up when they've lived independently before. ...

What kind of community is Ashtabula?

Ashtabula is a small town, and it may be growing in size, but it's maintaining its small-town mentality. We are one of the highest utilizers of Medicaid in the state of Ohio, which means that most of our families are falling below the poverty level and are getting some kind of public assistance in one form or another. I can't give you exact statistics on race, but I would say that it's probably Caucasian primarily, with a good proportion of African Americans and pockets of Hispanic communities throughout the county. There's also a huge rural component to the county, areas like Orwell, Andover, Jefferson, what we call south county. Takes a good 45 minutes to drive there. Those people are even more isolated and probably have even less services available to them. So I would have to say that we are close to Appalachian-like in terms of finances and resources and those kinds of things.

So, not a lot of extra dollars for the mental health community.

No. No extra dollars for the mental health community. ...

Are there very many group homes in this area? Are you a new model for what could be done and what was promised a while ago?

We hope that we are a new model for what can work with this population in this level of care. We've seen it work. It works really well. And so we hope that people pay attention to that and they see that we can start doing some things differently.

“Sixteen residents is a drop in the bucket. It's not even a drop. It's sort of like a little breeze blowing by the bucket.”

... There's one other group home that I'm familiar with in this community, but there's no treatment there. It's a group home where people sleep and live. ...

... We have some fabulous group homes in the state if you have money to go there. ... We call them the Betty Fords for mental illness. Most of the clients cannot afford to live there. We have one that's not too far from here, and it costs upward of $50,000 a year to live there. Clients don't have $50,000 a year. Very few people have those kinds of resources. ...

How much does it cost to be here? How do these guys pay?

We have a room-and-board fee of 70 percent of a client's income. So whatever the client has for income, whether it be from Social Security, Social Security disability, they pay 70 percent of that income in rent. And of course clients have Medicaid, and so the mental health services are covered by Medicaid. ...

And so what is the average cost for somebody?

Most of the clients receive Social Security disability. They're paying about $420 a month. ...

This place was designed to do what? What are you trying to accomplish with this?

Bridgeview Manor was designed with the idea that not only do our clients need a place to live when they come out of the state hospital -- and a stable, safe place -- but they also need a higher level of care than what's available in the outpatient treatment milieu. Most of the time, these patients would go to see their psychiatrist once every three months; they would maybe see a therapist once a month, but some of them probably weren't even eligible for therapy; and they would receive case management sometimes three times a week. What we've found is that with the chronically mentally ill, they require a much higher level of care, but not quite hospitalization. And of course, hospitalization is not available in the long term, so we have to come up with a solution.

So what we tried to design here at Bridgeview Manor is a place where clients' housing needs are met, first and foremost. So we have stable housing. And there's no predetermined length of stay, so the clients don't have to worry that they only have three months to get it together. ... The thing that we do differently here is, we provide the mental health treatment here in the house. Clients who live here have access to individual mental health therapy, Partial Hospitalization Programming [PHP], which is group treatment, and case management, all within the house. Because we, of course, are a part of the North Coast Center, our office is just a couple of blocks away, and the only treatment that clients really need to go out of the house for is psychiatry appointments with the psychiatrist.

How many live here, how sick are they, and what do you do for daily needs?

Bridgeview Manor is home to 16 adult males, all of whom are diagnosed with a severe and persistent mental illness. Primarily, the folks that live here have been diagnosed with schizophrenia. We have on occasion had folks diagnosed with bipolar disorder, bipolar disorder with psychotic features, schizoaffective disorder, and of course some Axis II disorders [personality disorders]; also clients that are dually diagnosed with both drug and alcohol issues at the same time with their mental illness. ...

In addition to the clinical [diagnoses], how sick are they, and what kinds of help do they need?

Most of the clients here at Bridgeview, because of their … mental illness, need a lot of additional help that's not available particularly in an outpatient community kind of setting. They struggle with things like daily hygiene, tooth brushing, taking a shower, washing their clothes. Many of our clients, particularly initially when they move in, don't know how to operate a washer and dryer. They don't know how to operate a stove or a microwave. They may have been going to soup kitchens, and other people have been helping them with their meals.

They really struggle to access their benefits. It's a huge issue that we have when clients move in. They don't have the skills to navigate the system in the community to apply for a Medicaid card, apply for a Food Stamp card, get [their] Social Security application moving. People need help with things like: I don't have pants, I don't have shoes, I don't have a winter coat. So essentially, when clients live in this facility, we are able to assist them in doing all of those things while they live here. ...

We are dealing with clients, of course, who have severe and persistent mental illness. Many times they're fixed and delusional. So the level of care, of course, is individualized to each client, and we have some clients function a little higher than other clients. But we have clients that we've had to teach to take a shower. We've had clients who are not oriented to time or date, so they don't really know what year it is. We've had clients get lost in the house, and we've had to come up with creative ways to get a client to the right bedroom. And we numbered all the bedrooms. And in one case we gave a gentleman the matching number to carry in his pocket, so he could refer to that to find his bedroom. …

There are 16 gentlemen here, and just like if we lived with 16 other people, it gets a little hectic. So we do a lot of arbitrating disputes, mostly over coffee and cigarettes. We have to help clients a lot with learning what their medications are, what they take the medication for, and do a lot of reality ... orientation. Many of our clients spend a great deal of time not in reality, so our job is to bring them back as much as we can and kind of challenge their irrational beliefs a little bit and keep them focused and moving in the right direction. ...

And [we do] a lot of motivation, too, just really trying to provide some energy. The medications are very sedating. Clients are very tired, and I think that they're accustomed to people just kind of pushing them aside and letting them be. And when they come here, we don't allow that to happen. We don't allow televisions in their bedrooms, because we don't want people sitting in their room all day watching TV. So we try to implement little changes that overall will make a bigger global impact on this illness and on the lives of people who suffer from this illness, that they actually will have better quality of life. So that's what we're trying to do here. …

What's a typical day in the life here? What do you have them do, and why? ...

... Usually staff comes in, and part of our job is to wake the clients up. And that sometimes takes a while. We've purchased all the clients alarm clocks, but we have to teach them how to use them, or to encourage them to choose to use them. And of course part of that is, a lot of the medications that they take are very sedating. ...

Once clients are awake, they start with medication administration. Most of the clients here have been here a while, and so a lot of them are really good at navigating their own medications. They know what they take. They can fill their pill keepers. Many of the clients, when they moved in, they would swallow anything you gave them. They were accustomed to just having someone pour their pills in a cup, "Here you go," and they would swallow them. We really encourage clients to become empowered: Know what you're taking, know what it's for, what does it look like, what's the dosage, side effects, reporting side effects. ...

Then we move on to the PHP [Partial Hospitalization Program] groups in the morning, which cover all kinds of things: skill building, anger management, coping skills, communication skills, social skills, learning to identify your own emotions, learning to express them appropriately, a lot of work around boundaries and being appropriate with other people. Basic, day-to-day kinds of things that you and I take for granted, that are just natural to us, these clients really have to work at.

We like to do a lot of really creative things, too, in terms of making it individualized to each client. A lot of our clients have struggled with family issues or problems. Their families take advantage of them, or they have nothing to do with them. Many clients have families that come around when the Social Security check is coming in or when the Food Stamps were coming. So we work a lot on the clients being able to set healthy boundaries with other people. ...

Following PHP, essentially they have free time. They're allowed to engage in any activity that they want to engage in that's legal and not against the rules, but case management is available. Clients can work with their case managers in the afternoon to attend appointments, access their benefits, maybe go shopping, may need to buy cigarettes, they want to go visit someone in their family. A lot of our clients like to ride the bus out to the mall or to other places. So the afternoon is kind of free time for clients to do what they want. Bridgeview Manor is not a locked facility, so there is a very homey component here. And following the real intensive treatment in the morning, the afternoon is kind of designed for clients to essentially pursue things that they want to pursue.

And then of course, as we move into the evening, we have, again, medication administration by staff. And then clients again have more free time.

[Do they have] dinner together?

We have three meals a day and snack time twice a day. Most of the clients eat together in the dining room, so it's kind of family-style dining. They do that for all three meals of the day. We really encourage clients to eat here, because we want to make sure that they've eaten. Most of the clients eat here; they don't really like to go out. Sometimes they, for a special treat, will go out for lunch, but they're usually always here. ...

In terms of the illness, what other kinds of issues do you deal with?

We see a lot of different kinds of symptoms of the illness. I'm speaking primarily of schizophrenia because that's what most of our clients here have. We see hoarding; we see stealing; a lot of paranoia, lots of accusations toward one another: "You're looking at me"; "you stole this from me"; "you're following me," those kinds of things. Very bizarre, ritualistic kinds of behaviors and belief systems. For instance, if I put my hat in the freezer, someone won't eat the eggs. And if I have 52 radios, I can alter the size of my clothing. ...

Why is hygiene such a big thing? Why wouldn't one know to wash oneself?

I think that the inability to recognize the need for hygiene is part of the illness in that most of the clients who suffer from schizophrenia are not really reality-based, so they're not paying attention to things that you and I are paying attention to. They're paying attention to: Is that FBI man still following me? And am I still transmitting radio waves? And if you can imagine just being bombarded with sounds and images and voices all day long, hygiene is probably not your top priority. Maintaining your safety and your integrity is probably your top priority.

We have other clients here who, as a function of their illness, think that soap is dangerous, or that if they wash, they're going to lose the special power that they have to transmit messages to another dimension. We've heard all kinds of reasons why hygiene isn't important. Could it be related to their history of being homeless, living on the streets? Absolutely. We've had clients here, when they first move in, that we really work diligently to just get them to not dig through the trash when they're looking for something, whether it be a plastic bag or an empty pop can or even partially smoked cigarettes. ...

Dental hygiene is another huge issue here. I would have to say that a good 80 percent of our gentlemen have had to have, or are going to have to have, teeth pulled, needing dentures, don't have all of their teeth. ... A lot of our gentlemen, when we gave them a toothbrush and toothpaste, they were like, "I haven't had one of these in years." ...

Many guys wear headphones. What's your view of that?

Many of our gentlemen wear headphones, and I think the reasons for that are varied. We have some gentlemen who wear headphones because they like music. We have other gentlemen who are wearing headphones because they believe that those headphones are receiving and/or transmitting messages to other people. We have gentlemen who wear headphones because they believe the headphones can alter the size of their pants or [the way] they feel today. ... Many clients report that when they wear headphones, they don't hear voices; they turn the music up really loud so that they don't hear the voices. And other clients say that they wear headphones so that they can access the voices, and the voices have a way to talk to them. ...

Smoking?

Almost all of our clients here smoke, and I can't honestly tell you what the correlation is between schizophrenia and smoking, but obviously there is the correlation. These gentlemen consider cigarettes a need, not a want. We've spent a great deal of time working with residents to determine what's a want and what's a need, because again, they live on very limited incomes, so things like cigarettes and candy bars and pop become huge issues. Cigarettes are like currency in this house, just like in a prison. And they know who has the most money; they know who has the best cigarettes. ...

How many of these guys could live on their own? Where were they living before they found their way here?

Most of our clients, before living here, were living in various states of squalor and disarray. We've had clients that were living independently, but in places that you and I would consider uninhabitable: without a bed, without furniture, very dirty, maybe didn't have heat; maybe they lived in a crowded apartment or housing place that other people shared. We had one gentleman who lived in an apartment that he was paying almost all his Social Security check to live in, and his mattress was as black as coal. You wouldn't have imagined it had you not seen it for yourself. It was a filthy, horrible environment. No smoke detectors in the house, lots of people living in the house, very few exits.

We have some gentlemen who were living with family members, but [it] became very stressful for the family members to cope with the illness, to keep clients compliant with their medication. Clients come from homeless shelters; clients come from [being] homeless, period, without living in the homeless shelter. We've had other clients who have come from having been incarcerated, or even as an alternative to being incarcerated, like a last-chance kind of a deal. ...

What role do families play in the lives of the residents here?

Some of our residents have family involvement, and some of them don't. We've had residents that have previously lived with family members, but for various reasons the family members find themselves unable to continue to care for the clients. In some cases it's because the family members are elderly, or they're anticipating that as they grow older, they want to make sure that their children have a place to live and that they're well taken care of and that someone's meeting their basic needs. ...

We have some gentlemen who, after living here, have re-established connections with their families. I think the families feel a huge sense of relief that the clients are well taken care of, and so there's a little bit more security in re-forming relationships and bonds. Many family members are sometimes nervous that the client is calling again for something else, or a lot of parents have told us, "Oh, I thought he was going to call me and ask me to move back home again or ask me for money or tell me the FBI was following him." And so they're pleasantly surprised to learn that the client is calling to reconnect and invite the family here: "This is where I live. This is what I'm doing." ...

One of the things that we'd like to see is that we incorporate perhaps a family group for parents or siblings or other close relations to the clients that live here so that they can kind of garner support from one another. There's not a lot of community support available for families who have folks that have mental illness. ...

What are the problems of the severely mentally ill coming out of prison?

For our folks coming out of prison, we face a whole new set of challenges unique to the population.

Clients have to have identification to access benefits. You're not allowed to access benefits until you're actually released from prison, so most inmates are given an identification when they leave. But if there's some snag, like they can't verify their Social Security number or their birth date, then they don't get an ID, which means we can't fill out the Medicaid application without the identification. So then we backtrack, and we find out where was this person born. We hope they can remember. We do have a gentleman here who cannot remember, and we've tried, and the guardian has tried. We still don't have a birth certificate because we don't know. But we try to get a birth certificate for the client.

Now, again, if a client was just released from prison and sent into the community, they would already at this point break down and not be able to do these things, because number one, birth certificates cost around $20; number two, you have to know where to go to get one. And the clients are usually put on a bus and sent to wherever they're going with some money in their pocket, and that's that. They haven't probably really practiced wants versus needs and how to manage this $85 that you've given me, and I need to get a birth certificate.

So after we get the birth certificate, then we have to double back to the Social Security office if they don't have a Social Security card to try to get that. Then you can finally take these two pieces of identification to Job and Family Services to apply for your Medicaid, which they have 30 days to activate the Medicaid, if you're eligible. So for 30 days, the client has no insurance, no benefits.

They're released from prison with two weeks of medication. So already we have a client with two weeks of medication, and it's going to be 30 days before he even sees an insurance card. So there's going to be a two-week period of time where the client is not going to have any medication. Client's probably going to get frustrated, is going to develop symptoms, is going to decompensate and isn't going to follow through with those kinds of things. So, again, another opportunity for a breakdown in the system. ...

So in a facility like this, we're very fortunate because they can at least have a stable house and at least have some support through this horrible process. Things like getting clothes -- clients come out of prison, and they don't have clothes. So we've got to take them to various areas in the community where maybe we can get a voucher to shop at Salvation Army or Goodwill; maybe we can go to the Dream Center where they can pick up some clothing. And [we] hope that all falls into place, and they can accomplish those kinds of things.

But again, it's lots of hurdles to jump through. And I imagine that for a client who has been incarcerated and has a mental illness and has no support, this would be an almost impossible system to navigate through. ...

Explain how schizophrenia in particular can make the transition from prison even more difficult, beyond the practicalities of navigating the benefit system.

... We see a lot of people that come out that have schizophrenia, that have their two-week supply of medication, and, best case scenario, they take it for two weeks. But after those two weeks are up, they probably haven't navigated the system. They probably don't have a follow-up appointment to get the medications, so they stop taking the medications, and they start to decompensate.

When they start to decompensate, they engage in behaviors that you and I and the general public consider to be strange, nuisance behaviors. They're troublesome. They start to talk loudly to themselves, gesture wildly. Perhaps they start to ask people for money. They hang around in front of storefronts. They go to the mall, and they bother the general public. And then the public starts to complain. And naturally, when the public starts to complain, well, then they usually call the police. The police come, client is psychotic -- police are most likely a trigger for a psychotic person -- and so the client's behavior escalates and escalates and escalates. The police response to that is usually to arrest the client for disorderly conduct or some other nuisance kind of charge.

If they've come out on probation or parole, a lot of times, that's a violation of their probation or parole, so they end up right back in jail. So I think that we see that happening a lot, for really nuisance, minor kinds of charges: stealing cigarettes, creating a public disturbance, loitering. All those kinds of things are the kinds of things that ... we see clients getting arrested for, and then back into the system. ...

William Stokes came in yesterday. How do you know him? [Can you give us] a snapshot of his psychiatric history?

Mr. Stokes came to my attention many years ago, again, when I was doing prescreening work in local hospitals. I had prescreened Mr. Stokes several times for involuntary admission into the state psychiatric facility based on self-mutilating behaviors. ... And then we were contacted about Mr. Stokes being placed here following his release from prison. ...

I think that in terms of a client, Mr. Stokes is a huge risk because he has a horrendous history of self-mutilation. ... He has a history of drug and alcohol addiction. He's coming back to the community where he used to engage in these kinds of behaviors, where the only people that he's friends with are the people that he was friends with before he got locked up. He is isolated from his family, he doesn't have a lot of support, and he's not on probation or parole. ...

How's he going to do here?

I think that if Mr. Stokes can accept the treatment that we're going to offer him, and if he can agree to follow the guidelines that we're going to set up for him, as difficult as they're going to be and as unpleasant as they're going to be for him initially, I think he can be successful. I think that's a big "if," again, because this is a huge jump in levels of care.

He's been incarcerated for 21 months, locked up. And then, on his 21st month and one day, he comes here. We are not a locked facility, and we say, "You have to participate in group, but after that, your time is your own." That's a huge difference in level of care. And it's a lot of freedom for someone who hasn't really practiced having freedom and choices and responsibilities on the outside of prison. So it's probably the best case scenario, and hopefully if he can accept the treatment and do the things that he needs to do, make the right choices, he'll be successful. But there are a lot of factors going against his success. ...

[The last time he was incarcerated,] he was in for three years and released, went to a shelter. Can you compare this time out to the other?

I know that the last time that Mr. Stokes was released, he went to a homeless shelter, and as I understand it, he ran out of his medication, didn't have the ability to fund his prescription, probably because he didn't have the support to follow through with Job and [Family Services] and apply for the Medicaid and all of those things that we had talked about before being challenges. So he ran out of pills, and he started to decompensate. And he started to get aggressive and angry and psychotic, and he started to hurt himself, and he started to engage in criminal behaviors to aid him in self-medicating. So he switched from taking his medication and not having any money for that to hanging around some friends who were able to give him some drugs to make him calm down and feel a little bit better, and so he engaged in a lot of behaviors that got him eventually locked up again. So he fell immediately into that crack in that two-week period of time where he didn't have his medication.

If you hadn't taken him this time, what would have happened?

If we didn't take him this time, he would be at the homeless shelter, and he would have medication for two weeks, and the exact same thing, I can almost guarantee, would have happened to Mr. Stokes. He would have fallen through the cracks, stopped taking his medication and been back in prison in no time. ...

Are there limits on homeless shelters? How many are there in Ashtabula?

Ashtabula has one homeless shelter. I am not certain of the capacity of the homeless shelter, but I do know that you have to be out in the morning and you're not allowed back until the evening. And you're allowed a 30-day stay one time a year. So if you're homeless for more than 30 days, or if you're homeless for more than once a year, you can't go back. Also, if you didn't behave the way that you were supposed to behave when you were there, you're not allowed to go back. ...

How will Mr. Stokes fit in with the guys, do you think?

I think that Mr. Stokes will struggle a little bit initially to fit in with the guys. I think that he perceives himself to be healthier, smarter, probably more sophisticated than a lot of our gentlemen here, and I think that that will make it difficult for him to initially fit in. I think that he, because of those feelings, will seek outside support, and the only outside support he knows are the people that he knew before he got locked up. So if Mr. Stokes can accept and find some commonalities among the people that live here, I think he'll fit in just fine, because he is similar, very similar to the clients that we have living here. But again, one's perception of the illness oftentimes colors how they behave.

It's hard for me to imagine him psychotic. You've seen him that way. What have you seen?

Mr. Stokes, when he's psychotic, is frightening. He's aggressive. He's a spitter; he's a cutter; he's a biter. He's very, very hostile, and he's very difficult to control. And that would probably be it, in a nutshell. He is one of the most difficult clients that we've probably had. He has been seen, I would hazard to guess, upwards of near 100 times in the emergency room, and hospital staff and staff across several counties are familiar with Mr. Stokes. ...

So appearances really can be deceiving.

Appearances are very deceiving, particularly with this illness, I think. ...

A number of guys have told us they committed crimes to go back to prison, and a number of them received their first mental health treatment in prison.

I have to say that oftentimes I have said to myself or a colleague, "Well, you know, I really wish they would get arrested and go to prison, because then they would get long-term care," because they would be there for the duration of their sentence, getting treatment. I think, unfortunately or fortunately, depending on how you look at it, prisons have become mental health treatment centers. And in many cases, a person is going to get a better level of care while incarcerated than they're going to get if they live in the community. And that's really sad, but I know it's factual. And I think that Mr. Stokes is a good example of the kind of treatment that's available in prison, because again, remarkable changes for Mr. Stokes. He's out now, and we'll see what happens. But he's someone that I imagine, if he hadn't landed there, would be in a completely different situation.

The promise of deinstitutionalization of the mentally ill, community-based programming -- you're still dealing with the legacy of that failure?

I think we're dealing with the legacy of deinstitutionalization in a lot of ways. It was a nice idea, but it seems to me that someone had an idea, and they went ahead and deinstitutionalized everyone before they figured out what was going to work on the outside. And so what we're seeing, of course, are people that are homeless, that don't have the skills to live in the community, so they're engaging in negative behaviors; they're getting arrested; they're getting into trouble; they're bouncing in and out, in and out of the hospitals, because we went from institutionalization to nothing. And so here we are now, scrambling to say, "OK, we have to have something." And ideally, obviously, this would have been designed prior to deinstitutionalization so there could have been some planning. ...

You can force somebody [to take] medication in prison; you can't do it in the community.

We cannot force medications in the community. Under rare circumstances, you can still mandate medication in a state hospital. The legal system, of course, can mandate medication. We would love to be able to mandate medication in certain circumstances, but we can't. ...

For someone who's been incarcerated and mandated to take medication, and comes out not on probation or parole, it really doesn't take a lot of brains to realize that "I don't have to do this anymore if I don't want to." And so a lot of people become noncompliant. The side effects with medication -- I mean, there are a lot of reasons that clients don't want to take their medications. ...

Is expecting a paranoid schizophrenic to have the insight to want to take the medication a massive failure of understanding, though well intentioned?

I think it's difficult to convince a client who is not reality-based at all to take some medication, particularly with schizophrenia because most of the symptoms that we see are paranoid symptoms, persecutory delusions -- "and now you want me to swallow this pill?" Most of those kinds of things are unrealistic.

Many clients go home, and they throw the pills in the garbage because they think they're poison. Or they cheek their meds, or they put them in their pocket. We've found a lot of strange places that clients will put medication, and when you talk to a client about it, you realize the client doesn't really have the insight to recognize the benefit of this medication. So leaving it up to them is really kind of a moot point. It's not going to work. It's not good treatment, although, on the other hand, there's a very fine line, it seems, between client rights and what's best for the client and who gets to decide that.

However, I think that a person who's not focused, not based in reality, how can they be able to make a rational, good, conscious decision about what's best for them? We have rules and laws governing who can consent in terms of minors, in terms of mental retardation. We don't really have a lot of that in terms of mental illness. We have clients who go out and they sign leases, and they get credit cards, and they get cell phones. And you and I would say: "Who would do this? Who would give someone a credit card?" But there's no allocation; there's no clause for the client not being able to consent. So it's a very, very frustrating kind of thing to deal with in treatment.

Do you see it as a social failure, a moral obligation that we're not meeting?

I see the whole system as a huge social failure and a huge moral obligation that we're not meeting. I like to imagine that most people just figure it's taken care of, because they don't see these people. And I learn this by talking with my family, with friends who don't work in the field. They just sort of think that everything's hunky-dory: "Oh, yeah. Well, all those people are in hospitals, right?," or, "Well, why can't they just go get some medication?" And there's a real assumption socially that things are just provided and taken care of and it's just OK. ...

I know the ambition is independent living. Is there also a segment of the population of severely mentally ill who will always need supervised, structured care?

There's a huge segment of the population of people that are diagnosed with severe and persistent mental illness that will need this level of care for the remainder of their lifetime. That's not the popular view or the one that we like to think is ideal. And there are very many clients that will be able to manage independent living, but with additional assistance, particularly with medication compliance. Even the clients that we have moved to independent living, they still come here twice a day to take their medications.

So we like to say that part of the reason that they're so successful in living independently is because they still have the guarantee of medication compliance, which is what helps people stay safe and healthy in the community. And we know that with a lot of these clients, if we asked them to manage their own medications, they would get confused, they would forget, they wouldn't take them, and that would start over again. ...

And without that, we're just deluding ourselves that this is going to be --

I believe, without that, we're right back to where we started. ... I think that clients get used to having the support, and so being able to come back here and take medication and remain compliant is helpful. When we move clients to independent living, we try to keep them in like a two-block radius so that it's really easy to get back here. When they feel like getting something to eat maybe, or they didn't manage their Food Stamps so well and they don't have something for dinner, sometimes they'll come back and eat dinner here. But they always come back to take their medications.

With 16 residents, is there a greater need than you're able to serve?

Sixteen residents is a drop in the bucket. It's not even a drop. It's sort of like a little breeze blowing by the bucket. I get calls every day for placement. I get calls every day for a waiting list. People are coming in usually at least once a week to tour the facility, to get their name on a waiting list. I think the problem that we're seeing is that most of the time when a client needs this level of care, it happens really quickly. They get evicted from their apartment; they're going to get discharged from the nursing home, and no place will take them. Their parents kick them out of the house; they get released from prison. These things happen pretty quickly; not a lot of planning involved. So those are a lot of the kinds of calls that we get, are for immediate services.

So a lot of times, by the time I have a bed open up, people on the waiting list have already been incarcerated; they're in the hospital; they're in a nursing home. They've moved on to some other Band-Aid kind of a facility because this one hasn't been available.

We're in the midst of the largest exodus of prisoners in U.S. history. A huge percentage will be mentally ill inmates. What should communities expect across America?

I think communities should expect to see more homeless people. I think communities should expect to see an increase in demand for indigent kinds of services. But I think more than anything, police departments will be busy again. And I think that the exodus will be followed by an entry of incarceration. I think that those people that come out will circle around for a little while, and then I think they'll be right back. I think that's what communities should expect, and I think that's what the prison system should expect, because again, in terms of treatment, they're the top provider, because when someone gets incarcerated, they don't really have a choice. When you've got someone for two years, you've got them for two years. So I think that communities should expect to see it fail miserably, and they'll be right back to where they started.

posted april 28, 2009

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