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Success in the Big Apple

Monday, June 14, 2004

Success in the Big Apple
New York City finds path for mentally ill
Housing homeless before treatment bucks conventional wisdom



New York - -- Shopping for telephones is what finally drove it home to Tony Bartol that he was re-entering that almost-forgotten world where the sidewalk was not his bed. He stood in front of a wall lined with 200 of them in plastic packaging -- white phones with speakers, black ones with six lines, red ones with voice mail -- and scratched his head, confused.

"I have no idea what to pick here," he said. His hand trembled as he touched one, then another. "The last time I owned a phone was 1977."

A few weeks before, Bartol was sleeping in Manhattan subway stations, so mentally ill he could barely pluck reality from the visions of God in his head. He'd been that way for 19 years. On this day in mid-May, the 54-year-old, bushy-bearded string bean of a man was in a department store with two social workers shopping for a few essentials before moving into his own apartment.

He was still delusional, still without a job, and still not on the medication he needed to address his psychosis. But now, he had one angel over his street-tough shoulder that other mentally ill homeless people still foraging in alleyways didn't -- a program called Pathways to Housing, a New York-minted twist on the "supportive housing" model of tackling chronic homelessness in urban America.

Unlike other cutting-edge supportive housing techniques in New York, Philadelphia, Chicago -- and being embraced in San Francisco -- in which the hard-core homeless are moved en masse into residential hotels with on-site social services, Pathways to Housing snatches them straight off the street and gives them their own, individual apartments apart from other homeless people, alongside average New Yorkers. And unlike virtually any other program in the country, it does this with the hardest core population of them all: the mentally ill.

"God has a plan for me," said Bartol, as he loaded a $16.95 Coby phone into his shopping basket. "I don't know what it is, but I know this: I've got to move inside, or I'll die." He clenched his teeth, then let a hint of smile creep onto his lips.

"I think these guys can do that for me," he said, gesturing to the Pathways social workers. "They're the only counselor types I ever met who were just straight up with me.''

Traditionally, social programs only give the homeless places to live once they've gotten clean of drugs and alcohol, been analyzed by counselors and put on mental health medications if they need them -- in other words, made "housing ready."

Once inside, the homeless traditionally are grouped together in building complexes for support and easy access to social workers.

Not at Pathways.

For 12 years, the program has been pioneering what is called the "housing first" strategy of whisking the homeless into permanent residences with no in- between steps of counseling or transitional shelters required. Even more unusual is the practice of placing them by themselves -- not in buildings full of other homeless people, but in apartment complexes of regular tenants who often have no idea who just moved in next door. It takes them even if they're still shooting dope, still drinking, still barely able to distinguish fantasy from reality.

And the amazing thing is that Pathways works -- mostly because it swarms its homeless tenants with continual counseling and programs to help them get their lives stable after they move indoors. The program is so successful that researchers and leaders from former President Bill Clinton to the homeless czar for Clinton's ideological opposite, President Bush, say it is setting a new standard in America on how to coax the hardest of the hard core of the homeless up off the sidewalk and into healthier lives.

All of Pathways' residents are mentally ill, and 90 percent are drug addicts or alcoholics -- yet 84 percent of those who move into Pathways stay housed. More conventional programs in New York that emphasize medical treatment, halfway houses or hospitalization for similarly mentally ill homeless people have only a 23 percent success rate, according to a recent study conducted by the U.S. Department of Health and Human Services.

In another age, many of Pathways' tenants would have been locked into mental institutions; and indeed, many have spent time in jail for indigence before, only to be put right back out on the street again. But because of the intensive counseling and individual empowerment method at Pathways, they don't just stay housed -- they live productive lives, going to college, holding jobs, and helping other homeless people get stable.

The achievement has had echoes all the way out to San Francisco, where homeless program planners in recent years have gingerly tried some of its methods.

Parts of Pathways' "housing first" strategy already can be found in the city's groundbreaking Direct Access to Housing program, which clusters hard core homeless people in rehabbed hotels and, like Pathways, takes them in whether or not they are drug-addicted or mentally stable. And its technique of dispersing clients in the general population -- called "scattered site housing" -- is a core value of Larkin Street Youth Services' equally groundbreaking program for homeless foster kids.

San Francisco's newly enacted Care Not Cash welfare-cutting program also entails moving the homeless into supportive housing as quickly as possible, after slashing their general assistance checks.

But, thus far, nothing in San Francisco approaches Pathways, placing the mentally ill in individual apartments away from other homeless people, regardless of stability -- though that may change.

As the city moves forward on drafting a 10-year plan to end chronic homelessness, there should be more Pathways-style techniques incorporated here, said Angela Alioto, head of the committee that has been charged with drafting the plan by July.

"Pathways is exactly the model San Francisco needs to get the chronically homeless off the street," Alioto said. "As a whole, transitional housing just doesn't work -- you have to give them a place to live right away, then deal with the problems.

"That's why our Direct Access to Housing works so well," she said, referring to the local program employing a housing-first strategy. "They're both wonderful, and we need more of them."

Pathways was the first program of its kind in the United States, and because it is still relatively small -- housing just 450 people out of New York's overall homeless population of 38,000 -- it is only known well to those who study homelessness closely.

Like former presidents.

"Pathways is a good example of what I call social entrepreneurship -- people who have really figured out how to solve our common problems in new ways," said ex-President Clinton, whose office is in the same Harlem building as Pathways' headquarters, in a recent interview. "You need programs like this because just one size, one approach doesn't fit all, and you can't just stick to the old way of things if they aren't getting the whole job done.

"This program is innovative and it's leading the way for the rest of the country."

President Bush's point man on homelessness, Philip Mangano, has one word he often uses for Pathways: "Astonishing."

"Ask a homeless person what they want, and they won't say they want a pill or a program -- they'll say they want a place to live," said Mangano. "Pathways does just that. It gives them a place to live. The rest you can do once they're inside."

The superlatives draw a shrug from the man who founded and runs Pathways, Sam Tsemberis.

"It just seems to me the most obvious way to do things," he said, walking down Third Avenue in Harlem to meet Bartol, to help him carry his three big trash bags of belongings on move-in day. "What's more obvious than giving a homeless person a home, and then helping them help themselves stay in it?"

Tsemberis came up with the Pathways technique when he was a New York City psychiatric outreach worker in the late 1980s. He watched the people that he helped, the homeless mentally ill, bounce in and out of hospitals and drug rehab programs with dismaying regularity. Back then, the only philosophy was that the homeless had to be clean of drugs and alcohol and have mental problems stabilized before they could be housed (an approach that is still the most conventional one used, even though most program directors around the nation have begun adopting a "housing first" philosophy).

"I kept having people fail over and over until I realized that what you need to do is take a scalpel and cut out all the intermediary steps," Tsemberis said. "No transitional program to speak of -- just put them straight into housing. Right off the street. Right away."

Having earned a doctorate in clinical community psychology, he knew a bit about writing convincing reports -- and so in 1992 he applied for and won a $500,000 grant from the New York State Office of Mental Health to found his brainchild. He started out with 50 apartments in Hell's Kitchen and Harlem.

Today, his annual budget is $11.3 million, drawn from city and state mental health funding and federal agencies, including the Department of Housing and Urban Development. The program maintains 450 people in apartments throughout New York and runs outreach teams from Queens and Brooklyn to Manhattan.

The program now has five New York offices -- and a new satellite in Washington, D.C. -- employing 100 people including psychiatrists, counselors, and vocation specialists, 80 of whom double as outreach workers. It offers classes on nutrition, adult education, gives psychiatric and substance-abuse counseling, and runs a bakeshop and a thrift store that both employ clients.

Residents pay one-third of their income for rent -- which typically means about $200 after they begin receiving federal or state disability checks of between $500 and $800 a month. Pathways picks up the rest -- and to help out with extra spending cash it gives the tenants jobs at its programs, cleaning, baking, selling or doing paperwork and helping other homeless people with laundry and the like.

The empowerment pays off quickly with commitment from the tenants: About a quarter of the Pathways tenants, whose average age is 40, are in school or hold jobs, and three-quarters participate in drug or alcohol rehab.

What makes Pathways' "housing first" approach work is that its homeless participants are not just dumped into their apartments and left. They are surrounded with services and counselors who not only visit several times a month, but make them feel so included and cared-for that they can't help but participate in the galaxy of job, counseling and rehab programs that the center offers at its offices. Which are always located near the apartments for easy access.

"The idea is to meet the homeless person where they are, be ready when they are, go at their pace," Tsemberis said. "Why would anyone want to live in a locked place, or even nearly locked place, where you are subjected to humiliating rules like children? How many Americans live under strict clean and sober rules in their own homes?

"If you relax those standards, you respect the people you are helping -- and they respect you. They had lives before, so we are trusting they can have lives again."

On its face, Pathways sounds similar to what America attempted from the 1950s through the 1980s, closing mental hospitals and putting the patients in community-based halfway houses. That approach has been widely dismissed by researchers as a spectacular failure, a major reason that at least 30 percent of America's overall homeless population of about 2 million is mentally ill.

The difference is that doctors then hoped that new medications would fully stabilize the patients in those halfway houses. They didn't, and patients would often abandon medication even if it was working.

Now, medications such as Zyprexa and Depakote are more efficient, but patients are still free to abandon them -- and many do. But there's something about Pathways' alchemy of surrounding the clients with programs and counseling, while still leaving them autonomous enough to live alone, that seems to work better than the old halfway house approach.

"A lot of people thought Sam was absolutely wrong back when he started out, and it's taken a long time to figure out he was the one who was right," Lloyd Sederer, head of New York City's mental health services, said of Tsemberis. "Now we want it to expand as fast as possible, and we think everyone ought to adopt it."

That's not to say it's all seamless skating. Outreach workers -- as in any intensive homelessness program -- sometimes have to visit the same street person for more than a year before they convince him or her to come inside. And 84 percent success still means 16 percent wind up back in the gutter.

"To do what we do, you have to be willing to assume some risk," said Tsemberis. "We have no locks, no warehouses for people on cots. It's just us, the landlords and the tenants. If someone screws up, the neighbors will know about it -- and we won't always be right there to handle it on the spot."

Paul Williams, 66, who lives near a couple Pathways tenants in Harlem, said he found them to be "just fine as neighbors."

"Listen, I'm live and let live," he said. "You bother me and I'll kill you. Otherwise? Fine. And besides, this neighborhood used to be drug infested, but it cleaned up around the time those people moved in. They're OK."

In the program's 12 years, there have never been any serious violent incidents. Sometimes residents have been evicted for flagrant drug use or not paying their bills because they were unable to get their lives together. But almost all have been drawn back in for second or even third tries -- and kept at it until they succeeded.

June White, 39, was one of those who blew it several times before getting it right.

She slept in Manhattan streets and bathrooms, eating out of garbage cans and railing at the voices in her schizophrenic head for a decade before a Pathways outreach worker found her six years ago.

"All they asked me was, 'where do you want to live?' and I thought it was a scam," White said when she dropped by the Pathways medical clinic to pick up her medications. "They put me in this apartment, gave me a bed, food, clothes -- I didn't know what to think."

First thing she did when the door closed, she said, was get high on crack. She stayed high for weeks, until she asked her Pathways counselor to find her a rehabilitation program. She did a month there, came back out to another Pathways apartment, smoked more crack, and went back into rehab.

"It wasn't until after 14 months of residential rehab that I finally got that they were serious," she said, laughing. "I started going to meetings, cooking good meals for myself, letting myself go to ball games and movies when the Pathways people offered, and so on. I connected. I had a community.

"I finally had something to care about."

Today, she is in her second year at Hostos Community College, studying nursing. She mentors others coming into Pathways, and keeps her one-room apartment on West 141st Street as clean as a whistle.

"Maybe some people would think this program is 'un-American,' because you shouldn't give things like apartments away to people. You know, the old 'deserving poor versus undeserving poor' argument," Tsemberis said. "But in a way it's very American. It fosters independence. And it saves money in the long run."

Each Pathways tenant costs $22,500 a year to support. More conventional supportive housing for mentally ill homeless people in New York costs between $40,000 and $65,000 a year, according to city records, and a mental services bed in a state hospital costs $175,000.

Tony Bartol, the new Pathways resident buying his phone, would fit right in among San Francisco's most troubled, mentally ill homeless people.

His face knotted with wounds from beatings and framed by a long, gray beard, Bartol walked along the sidewalk toward his new apartment with a wary gait acquired from too many years spent outside. Over his shoulder was a blue garbage bag stuffed with pots and pans, towels and drinking glasses -- all bought, with the telephone, on a $158 move-in shopping trip paid for by Pathways.

After struggling with the key of his room and muttering that he might have to eat the yapping dog across the hall for dinner to shut it up, he groaned happily and flopped down on his new bed inside. The bed was the main thing a Pathways outreach worker had promised him a month before when they met on the street, and here at last was the payoff.

"Shelters, drop-in centers -- you can keep 'em," he sneered. "God had a plan for me, and this is it.''

Two outreach workers and Tsemberis, who helped Bartol carry his things in, nodded. "You know, there are going to be people out there who will tempt you with drugs," Tsemberis said to Bartol, who claimed to have been clean of crack since 1998. "No way," Bartol said, clenching a fist: "I'll give them this."

Tsemberis sighed and said, "No, no, where's that 'love' thing?'' and he pointed to Bartol's knuckles, which had "love'' crudely tattooed across them. Bartol growled and the two chatted some more, the result being a tad fuzzy on how peacefully Bartol would handle a drug offer.

Tsemberis sighed again. One step at a time. Only go as far as the client is ready to go.

Then, as he left the building, Bartol called out: "Hey, can you give me a job?" and Tsemberis broke into a huge grin. "You serious?" he said, and Bartol nodded furiously.

"We'll talk, and I mean it," Tsemberis said, and as he closed the door behind him in the hallway he pumped a fist and whispered, "Yes!"

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