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March 30, 2009
Reprinted with permission from the .

By Kim Horner

In cardboard boxes under bridges, in tattered tents in the woods and in vacant downtown buildings live some of the hardest people to help.

They are the chronically homeless, those who suffer from mental illnesses and addictions and have been on the streets repeatedly or for years. Few are getting the care they need. Instead, they wander year after year between shelters, psychiatric hospitals, drug and alcohol treatment, and jail.

There's Jonathan Austin, who drinks beer while he gathers cans for recycling. And Tommy Pinson, who moved into a tent near White Rock Lake after he got out of jail. And Richard Antwine, who's been in and out of psychiatric hospitals.

There are at least 124,000 people nationwide who are chronically homeless and more than 1,000 in Dallas. Experts fear their numbers will grow because of the economy. They are the most visible among the homeless; the ones seen shouting into the air, walking into traffic and making people uncomfortable by asking for money.

The system designed to help – psychiatric hospitals, drug and alcohol treatment centers, mental health clinics and housing programs – isn't working for most of them. That failure not only perpetuates homelessness but ends up costing taxpayers millions for law enforcement, emergency care and other expenses that could be avoided.

"The system is just not there for them," said Ron Cowart, assistant manager of the city's Crisis Intervention Unit, which has a team that focuses on the most difficult cases on the streets. "I look at many of these [homeless] encampments as being monuments of our failure to properly address the mentally ill homeless."

The Dallas Morning News is taking a closer look at the struggles of helping the chronically homeless. This article is the first in a series this year examining the costs of inadequate treatment and exploring possible solutions. The project received support from The Carter Center, which offers fellowships in mental health journalism.

Though chronic homelessness is a nationwide problem, Texas falls behind most states in providing care at psychiatric hospitals and mental health clinics. That lack of commitment results in overflowing facilities and poor follow-up care that can set up the most vulnerable patients for failure.

The costs of leaving the problem unsolved are difficult to calculate. Many are hidden expenses, down to cleaning beer bottles and human waste from camps along freeways.
Dallas' new homeless assistance center, The Bridge, cost $21 million to build and another $7 million a year to operate. Terrell State Hospital, which handles the most extreme psychiatric crises, spent $1.7 million last year treating 132 homeless people. Dallas County spends about $11 million a year keeping an average of 566 homeless people per day in jail. And Dallas police have spent nearly $300,000 so far this year arresting 3,191 people downtown for panhandling, sleeping in public and public intoxication.

In 2004, the city created a 10-year plan to end chronic homelessness. But reaching that goal will be impossible without more housing and more mental health care and substance abuse treatment.

This year, local officials have asked the state Legislature for millions to provide more psychiatric care, housing and drug and alcohol treatment. Mike Rawlings, a businessman who serves as Dallas' point man on homelessness, said the requested funds will save money in the long run.

That's because while the chronically homeless make up only about 10 percent of the homeless population, they use half the services, such as shelter and health care. Studies have shown that it's cheaper to place people in apartments and provide intensive social services than to leave them on the streets.

That is the goal of Dallas' long-term strategy, to provide permanent supportive housing.

"The reason people are homeless is because they don't have a home, but fundamentally it's mental illness," Rawlings said. "Until we address that issue, we will have people on the streets."

Changing minds, lives

Winford Cross sees the damage from untreated mental illnesses and addictions every day.

The city of Dallas caseworker spends much of his time trudging through the woods and crawling under bridges, trying to persuade the most seriously ill people to accept psychiatric care and alcohol and drug treatment. He has been cursed at and spit on, and he often gets told no.

Robert Rushing, who had a mattress under the ramp onto Central Expressway downtown, said he would not abandon his dog. Duke stood by a nearby chain-link fence, wearing a Dallas Cowboys shirt to keep warm.

"There's nothing I can say to you to make you change your mind?" Cross asked him as cars rushed overhead.

Rushing, 51, looked down and shook his head.

Jonathan Austin, the man who regularly pulls a red wagon along Second Avenue in South Dallas, agreed to meet Cross a few days later to go to The Bridge. Barely audible, his face peeking out of a hooded black jacket, the 40-year-old said he'd been homeless for 10 years.

But when the time came, the man could not be found. Cross wasn't fazed.

"In a given week, if I set seven appointments, I'll be happy if I get two to show up," he said.
Cross goes to great lengths to reach out again to the no-shows – if he can find them.
On one near-freezing morning, he steered his truck along a dirt trail into the woods near White Rock Lake until he spotted a couple of tents hidden in the trees.

Two homeless men living in a small camp strewn with beer, wine and vodka bottles broke a promise to meet the caseworker by East Grand Avenue at sunrise.

Cross woke them up.

"You didn't think I was going to give up on you," he said as the bleary-eyed men climbed out of their tents.

Dustin Rockett looked in a mirror nailed to a tree, next to a broken recliner before they left their home in this quiet spot in the middle of the city.

Cross took the men to The Bridge. Rockett, a vet with a dishonorable discharge, got frustrated with the crowds and left the next day. Tommy Pinson, who'd recently gotten out of jail on an assault charge he denies, continued to stay at the 300-bed shelter.

Not enough help

When Cross does persuade a homeless person to climb into his pickup, his job can get even tougher. There's just not enough help to go around.

He takes many to The Bridge, where they can see a mental health professional, get a shower and possibly shelter, though there are limited beds available. Some stay there hoping to transfer to rehab centers, only to be turned away.

Hollis Morgan sat one afternoon slumped over a picnic table outside the drug and alcohol treatment center Homeward Bound when Cross arrived to pick him up.

Cross had taken the 24-year-old from The Bridge to the Oak Cliff center early that morning, but Morgan couldn't get in.

"I know it's hard to stay encouraged after a day of letdown," Cross said as he drove Morgan back to the shelter. "If it gets tough this evening, look back on what you've done already."
Doug Denton, Homeward Bound's executive director, said his center would like to admit more of the people who come for help. But some don't fit the state's criteria for detox treatment. Others get turned away because the facility is full.

"We are bursting at the seams," he said.

Psychiatric hospitals also are strained and generally only take people who threaten to kill themselves or others. Terrell State Hospital, which had nearly 3,000 beds 60 years ago, now has about 300. And they stay full so often, the hospital has had to send people to other facilities in the state.

After treatment

Once they leave treatment, many chronically homeless people do not follow through with their care.

"We send a patient out, and they come back a week later with the prescription still in their hand," said Thomas Collins, chief executive officer of Green Oaks, a psychiatric hospital that sees 1,200 people a year, many of them homeless.

Failure to take medications is the top reason people are readmitted to Terrell State Hospital, Joe Finch, the hospital's superintendent.

Less than 20 percent of those referred to outpatient care after being released from Homeward Bound ever actually make an appointment, Denton said.

Many people with serious mental disorders are not able to take proper care of themselves. And the system doesn't provide for anyone to help them.

Symptoms of severe mental illnesses can include confusion and disorganized thinking that make it difficult to keep appointments, fill prescriptions or figure out how to get to the clinic, said Dr. Joel Feiner, medical director of the Comprehensive Homeless Center of the Dallas VA Medical Center and a professor in the Department of Psychiatry at the University of Texas Southwestern Medical Center.

"We have to realize these are disabilities," he said.

Feiner advocates for more intensive follow-up care for people like Richard Antwine, a homeless man who roamed downtown streets one 40-degree night.

Earlier that day, the 47-year-old man had been released from Terrell State Hospital. He never showed up at a boarding house he was referred to. He said he had no transportation to get there.

"I don't like being on the streets," he said. "Sometimes I feel like getting in a corner and crying and stuff."

Antwine has been diagnosed with bipolar disorder, which is characterized by extreme mood swings. He also has a history of alcohol and cocaine abuse, which is not uncommon among people with untreated mental illnesses as they attempt to relieve their symptoms.

Antwine, who said he sometimes hears voices, said he has been in psychiatric hospitals at least 30 times throughout his life. He also has a criminal record that includes burglaries and auto theft.

That night, police officers directed him a few blocks away, to The Bridge. But he eventually made his way to another boarding house.

Having someone as vulnerable as Antwine back on the streets puts them in danger and at risk of becoming very ill again, said Feiner, a longtime advocate for people with mental illness.

Finch, Terrell State Hospital's superintendent, said hospital staff and mental health clinic caseworkers work with patients to find housing before they are discharged. But, he said, they cannot force the patients to go.

Jim Baker, chief executive officer of Dallas MetroCare, said the mental health system does not pay providers to find homeless people who do not show up for appointments.

Proposed solutions

Despite the many challenges, homelessness is not an intractable problem, said Rawlings, Dallas' homeless czar.

Rawlings – and experts nationwide – say the answer lies in special apartments coupled with intensive mental health services to keep people stable.

Even people who refuse treatment want housing, he said.

"I ask them, 'If I could give you an apartment and give you a key to that apartment and all you had to do was live there.' ... They all look at me like I'm an idiot for asking the question," Rawlings said.

But there isn't enough. Dallas has 744 units of permanent supportive housing and needs at least 700 more for the currently homeless. Hundreds more seriously mentally ill people who are living in substandard boarding houses also need decent homes.

The City Council recently agreed to spend up to $22 million over the next five years to create housing for the chronically homeless. But the city faces intense neighborhood opposition to such projects, fueled by images of stereotypical panhandlers and drug addicts.

But the housing won't work if it doesn't come with adequate mental health and drug treatment services. And the state's mental health system for the poor ranks 48th nationwide in spending per person.

Given the steep climb toward ending chronic homelessness, Dallas Mayor Tom Leppert and seven other big-city Texas mayors requested $25 million from the Texas Legislature for additional statewide mental health care and other services. Advocacy groups also are asking legislators for $380 million more statewide for mental health and addiction services.

No decisions have been made. But Leppert said the community cannot afford to ignore chronic homelessness.

"The issue of homelessness is not just a humanitarian issue," Leppert said. "It's a matter of saving dollars and cents."

FACTS ABOUT CHRONIC HOMELESSNESS

•Chronically homeless people have a disability, often a serious mental illness, and have been homeless for the past year or more or have been homeless four or more times within the past three years. Many also have substance abuse issues and other health problems such as diabetes, tuberculosis or AIDS.

•The chronically homeless make up only about 10 percent of the overall homeless population, but account for half the resources spent on homelessness, including shelters, psychiatric hospitals and drug and alcohol treatment.

•There are at least 1,000 chronically homeless people in Dallas.

•About 63 percent of them are African American.

•88 percent are men.

•51 percent reported criminal histories.

SOURCES: National Alliance to End Homelessness, National Coalition for the Homeless, Metro Dallas Homeless Alliance

Copyright 2009. Used with permission from Dallas Morning News.