Vol. 2 No. 2 Specials

Halfway down a busy street in downtown Honolulu, tucked between Hawaii Pacific University and a little café, is a respite for some of the most disadvantaged and stigmatized people in the city. Known as “Safe Haven,” the shelter is specifically targeted at mentally ill people among the large homeless population of Honolulu, many of whom have come from all areas of the continental United States, and from abroad. The people who take advantage of Safe Haven’s services go there to watch television, eat meals, engage in social activities throughout the day, and receive psychiatric and medical care.

Safe Haven is one example of a community-based response to the much larger, nationwide problem of homelessness among the mentally ill. A staggering two-thirds of those with serious mental illness end up homeless at some point during their lives. Community-based responses are the predominant treatment system for mentally ill homeless people; however, most homeless receive no care. Only one third of the homeless population in need of mental health treatment receives it; the rest are left to cycle between shelters, jails, institutions, and life on the streets. The effects of non-treatment are not only devastating to mentally ill Americans, but also expensive for the rest of society.

Prior to the 1950s, most people diagnosed with serious mental illnesses were committed to mental institutions. In the 1950s and 1960s, however, widespread public disapproval led to a deinstitutionalization movement that significantly decreased the population of institutionalized patients. Antipsychotic medication increased the freedom of patients to live on their own, and financial incentives like Medicaid and the Supplemental Security Income (SSI) program – a federal program that provides a monthly stipend for disabled people – changed the locus of mental treatment from institutions to communities. The Community Mental Health Centers Act of 1963 was designed to address the needs of the mentally ill, but most of the services and support systems provided by the bill never materialized. Mentally ill people not only lacked appropriate clinical care, but also often exhibited behaviors that made them susceptible to homelessness, including regularly missing rent payment, disturbing their neighbors, and neglecting normal household duties. At the same time, cities increasingly gentrified low-income housing and single room occupancy hotels, leaving many people suffering from mental illness with no housing options, and forcing them onto the streets.

To address this complex problem, the Community Support Program, a comprehensive model of community-based care, was developed to offer income and medical assistance, psychosocial rehabilitation, employment services, long-term support services, and case management to people with serious mental illness. The Stewart B. McKinney Homeless Assistance Act of 1987 became the only comprehensive federal response to homelessness. It included provisions for offering healthcare, including mental healthcare, to the homeless. In particular, the McKinney-Vento Act, as it is more widely known, established an innovative program known as Healthcare for the Homeless (HCH), a federal program with branches in all fifty states, which has the sole responsibility of providing healthcare to the homeless.