April 16, 1999

By Ronald Pies, M.D.

Mickey pulls the blanket around his shoulders as if to keep out the cold fog rolling in off the bay. The tourists are lining up for the next cable car run from Fisherman's Wharf up Hyde Street to Powell. The crowd isn't into Mickey tonight, though the strains from his harmonica are sweet and soulful in the late-night air. Some college kids toss a couple of dimes into Mickey's baseball cap, and he nods his head in thanks. Slim pickings, but better than last week, when the cops made another "sweep" and picked Mickey up for disturbing the peace. The voices in his head were loud that night, so Mickey made his music loud, prancing into the line of tourists, trying to tamp down the devil sounds. A cable car operator flagged down a patrol car, and the cops took Mickey to the ER at St. Anthony's. A few hours and 10 milligrams of Haldol later, Mickey is back down by the waterfront. The voices are less insistent, but they will be back, just like the cops. Mickey crumples up a prescription for Haldol and tosses it into the street.

San Francisco has a serious problem with its homeless population, which some say exceeds 10,000. It might be that the city's reputation for compassion has been its undoing-drawing hundreds of homeless individuals from surrounding cities with more draconian laws against loitering or panhandling. In San Francisco, as in Boston and New York, many of the homeless are also mentally ill. For those, like Mickey, who are doubly cursed, the American system of health care has clearly failed. These individuals have either been closed out of decent care or-as a consequence of their illness-have closed themselves out of the health care system. Many refuse not only the offer of shelter, but also any connection to the mental health system.

In her book, Falling Through Space, novelist Ellen Gilchrist writes the following about "home":

"This is my home. This is where I was born. This is the bayou that runs in my dreams, this is the bayou that taught me to love water. . . . This is my world, where I was formed, where I came from, who I am. . . ."

Gilchrist knows that home is something much more than a dwelling. It is the crucible in which our identities are compounded. Home is not only where the heart is-it is also where the self is. Consider how many of our songs, sayings, and books sing the praises of home: Home sweet home, There's no place like home, "Homeward Bound," Look Homeward Angel; You can't go home again, "I'll Be Home for Christmas." (How curious that when we want to return to the beginning of a piece we are writing on a word processor, we push a button labeled "home.") And then there is Robert Frost's poignant definition of home as "the place where, when you show up, they have to take you in."

A recent piece in U.S. News and World Report titled "Going Home" observed that "most us still have a place we call home, the gravitational center of families and memories." To be homeless, then, is to be in a world without spiritual "gravity"-unmoored from self and soul.

Thus, it should not surprise us that many homeless people resist attempts to move them into "shelters." It is not simply that they resent the rules and regimentation of such facilities, though many do. It is not simply that the homeless mentally ill are too deluded to see the need for shelter, though many are. Perhaps it is really that shelters are not homes. A communal dormitory can never afford that sense of solace and sanctity, of gravity and grace, that a real home provides. Sadly, many of the homeless mentally ill can never go "home." Some must remain in DMH residences or halfway houses; others may require indefinite commitment to a state facility. But even these poor substitutes for home are grievously lacking in many communities. Instead, under pressure from businesses and city councils, the police initiate "sweeps" designed to remove people like Mickey from our midst. But where will we "sweep" these individuals? Into what dustbin or under what rug?

We must find ways to be both more caring and more custodial when dealing with the homeless mentally ill. Yes, unfortunately, "custody" sometimes means involuntarily committing an individual to a facility for treatment. But the word custody is derived from the Latin custos, meaning guardian. There are many severely disturbed individuals among the homeless who truly need guardians, in both the moral and legal sense. Without a home to "take them in," these individuals must at least be guaranteed shelter and treatment. For a few, that may mean indefinite hospitalization. For most, well-supervised mental health residences may suffice. These residences, in turn, must be integrated into a system of care that provides not only outpatient treatment, but also genuine "outreach"-including visits from doctors or nurses, and medication provided on site.

We must find the money-and the will-to support this kind of infrastructure. We must do what we can to enlarge the lives of people like Mickey. We must do what we can to bring them home.

("Mickey" is a composite of several individuals I encountered during a trip to San Francisco. "St. Anthony's" is a fictitious hospital.)

Dr. Pies is a clinical professor of psychiatry at Tufts University School of Medicine and a lecturer in psychiatry at Harvard Medical School.