LIFE OUTSIDE THE HOSPITAL

SUPPORT IS SCANT FOR FORMER PATIENTS

Shealia Hughes, a 34-year-old former mail carrier, left Washington's St. Elizabeths Hospital Sept. 8 with several bottles of prescribed psychiatric medication, no money and the address of the House of Ruth, a shelter for homeless women on the unfashionable fringes of Capitol Hill.

Hughes, who had spent much of the previous two years at the federal mental hospital, had nowhere else to go. While hospitalized, she said, she had been evicted from her apartment; her belongings had been stolen after they were dumped on the sidewalk in front of her building. She was unable to stay with relatives who were caring for her son, so hospital workers gave her a bus token and suggested she go to the 84-bed shelter.

"It's better than living on the street or being in the hospital," said Hughes, who spends her days looking for a job, playing basketball at a nearby playground or walking around the Mall.

Hughes illustrates what health care workers say are critical deficiencies in the care of patients released from St. Elizabeths, a sprawling institution in Southeast Washington. Too often, psychologically fragile patients like Hughes are expected to make the difficult transition from a mental hospital, where all decisions are made for them, to life in a community unprepared for their return and unwilling to take them back. Not surprisingly, many fail.

On Oct. 1, 1987, the District will assume control of St. Elizabeths, the nation's largest and most expensive public mental hospital. The Barry administration's plan for the transfer, now before the D.C. Council, promises to end a bitter, 20-year battle between the federal government, which operated St. Elizabeths, and the District, which sent patients there and ran an entirely separate system of clinics.

The plan proposes to halve the patient population at the 1,600-bed hospital over the next five years and transfer 368 to quarters on hospital grounds that are deemed "transitional." By 1991, 400 of St. Elizabeths patients will, like John Hinckley, be confined there under criminal court order.

Mental health advocates question how the District, which cannot begin to serve the 15,000 chronically mentally ill people now in the community, will cope with 800 more psychiatric patients as well as the operation of a huge, aging public hospital. The result, many predict, will be longer-than-necessary hospital stays for some and a rise in the District's population of homeless mentally ill residents, currently estimated at between 2,500 and 7,500.

"I have four file drawers full of plans like this from the District which have all the right phrases and absolutely no meat," said Marlene Ross, a member of the court-appointed committee that monitors deinstitutionalization at St. Elizabeths. "There are no secrets. People know what works with the chronically mentally ill. The District of Columbia has avoided implementing something that makes sense."

Ross and other critics say that the problem is not that patients will be discharged from St. Elizabeths, but that the plan is vague about how they will be cared for once they leave. Furthermore, they say, it underestimates the number who need services, fails to spell out where discharged patients will live or how they will be supported, relies heavily on transitional facilities that have no expiration date and could become permanent, and provides inadequate incentives for new community programs.

David E. Rivers, the city's Director of Human Services, says he is "thrilled" by the plan, which provides the city with a "major opportunity to do things we have not done in the past."Critics Cite Serious Problems

Advocates say they fear that the new system may be little more than a continuation of the present one, which they describe as two warring bureaucracies more sensitive to considerations of turf and the dictates of paper work than the often enormous needs of the mentally ill.

The current system has serious problems:The District's four community mental health centers, which according to city figures treat 8,000 people annually, have no regular evening or weekend hours. At South center, which serves the city's poorest residents, a person in the throes of a crisis might wait as long as four hours and must see four different workers before receiving treatment. Lack of leadership has seriously hampered the movement of patients out of St. Elizabeths and the creation of community programs. In the past seven years, there have been six directors of the Mental Health System Administration. Outreach services -- mental health teams that visit shelters and the streets -- are virtually nonexistent. On the nine-member outreach team at South center, five positions are vacant. "We've never been fully staffed," said center director Conrad Hicks. The outreach team has been in operation since 1984. Psychiatric services to shelters are largely provided by volunteer doctors. At the House of Ruth, which housed 6,800 women at various times last year, one psychiatric resident visits two hours per week. "We've never had a psychiatrist from South or St. Elizabeths visit -- ever," said shelter director Sandy Brawders, who estimates that one-third of the 84 women in her shelter have histories of serious mental illness. The pharmacy at D.C. General Hospital, which dispenses medication to South patients, is so overloaded that it takes two days to fill a prescription. That means two trips for homeless people who may have neither the money nor the inclination to go. Despite recent improvements, shelter operators complain that the city's Crisis Resolution Branch and the police are slow to respond to psychiatric emergencies. Some callers complain they wait as long as two days for a visit from the crisis unit, which, internal statistics show, is dispatched on only 10 percent of the calls it receives. "A lot of times when we call the crisis unit, they say call the police, and the police tell you to call crisis," said Ann Baxter, director of Calvary Shelter. There are only 18 "crisis beds" in the city. People who need brief hospitalization often are admitted to St. Elizabeths because there are so few other places for them. Washington's seven private general hospitals have declined to expand their services to provide additional beds for uninsured psychiatric patients who may be hospitalized involuntarily. Resistance to group homes, the primary form of housing for the mentally ill who do not live with their families, is increasing. Last year irate neighbors succeeded in delaying indefinitely a group home for six mentally retarded women at 3601 Texas Ave. SE. This year D.C. Council member Nadine Winter (D-Ward 6) sponsored a bill, which was not enacted, that would have permitted neighborhoods to block group homes, a power they currently do not possess.

D.C. Council member Wilhelmina Rolark (D-Ward 8), who represents the neighborhood around St. Elizabeths, has vowed to "fight to the bitter end" a disproportionate placement of group homes in her ward. Advocates and policy analysts say there are few programs at the community mental health centers. "I've always been mystified at how little goes on in those centers," said Leslie M. Scallet, a nationally prominent mental health policy analyst who has served as a consultant to the District. "During my visits, I've never seen any therapy groups or any patients. It's just seemed like a big, empty building."

Gladys Baxley, director of the city's Mental Health Services Administration, which oversees the centers, disagrees. "We're doing the best with what we've got," she said. The centers, she added, are "operating under some tremendous handicaps," including staff shortages.

The chief problem, Baxley said, is that "patients have not found their way to services."

That attitude, critics say, exemplifies a major obstacle to community care. Patients who are frightened and disoriented are expected to demand services from a bewildering bureaucracy. The result is that many simply drop out of the system altogether.

"We have a hard enough time getting our licenses renewed and our cars registered," said Terrance Lynch, executive director of the Downtown Cluster of Congregations, a coalition of inner-city churches. "You can imagine how hard it is to get any kind of services if you're mentally ill and homeless."

Those who work with the homeless mentally ill say that services tailored to their needs are critical. "A lot of homeless people are severely isolated and frightened," said Brawders. "The clinics like them all fixed up and medicated. Most of our women are very streetwise. They can sense people who don't like them, and they don't come back."

One recent midafternoon, a visitor to South center, a grim, dilapidated building on the edge of a trash-strewn parking lot near the D.C. Jail, found the building largely deserted. Two prospective patients sat quietly in a waiting room. "That's a lot for this time of day," said center director Hicks.

The atmosphere at South, some advocates say, is depressing and demeaning. "I always get the feeling that I want to turn around and run away," said Celeste Valente, a social worker at Mount Carmel House, a women's shelter.

"I've taken clients over many times, and they're very rude. I went over once and a staff meeting was going on, and we had to sit there for the entire morning. They do intakes in the waiting room. A person comes out with a clipboard and says, 'What do you want? Why are you here?' and the person has to describe in front of everyone why they're there, which can be very embarrassing."

Georgia Butler, director of adult services at South center, said that patients might have to wait several hours for treatment because they are seen by four people who fill out separate sets of forms.

Butler said she does not think that a three-hour wait is a problem. "When they're sitting there, they know someone else is being seen," she said.

At night and on weekends, when the mental health centers are closed, the Crisis Resolution Branch is responsible for providing mental health services. Half of the 600 calls per month to the unit, now based temporarily at St. Elizabeths, come from families. The rest are from shelter staff.

Shelter operators say that services have improved since Dr. Robert Keisling, a respected St. Elizabeths psychiatrist, took over this year, but they say that he is one of the few psychiatrists who will leave his office to see people in shelters.

Cliff Newman, who runs the city's largest shelter, operated by the Community for Creative Non-Violence at Second and D streets NW, said the crisis unit routinely dispatches a nonpsychiatrist who is not empowered to dispense medication or authorize emergency involuntary hospitalization. A psychiatrist may be dispatched later if the unit deems it necessary.

"It's absurd," said Newman. "First you call them and they tell you they have to have a meeting to see if it's a crisis. Then if they decide to come out, it's a two-step process for someone who is in the midst of a psychiatric crisis. The way they deal with it, someone could get killed waiting for them."

Sister Mary Ann Luby, who runs a daytime drop-in center for homeless women in Northwest Washington, said she called the unit last month about a woman who had been hoarding maggot-infested food and exhibiting other signs of severely disturbed behavior. Luby, who along with CCNV staff members had made arrangements with Keisling to have the woman seen by a psychiatrist for a possible commitment, called the crisis unit. She said she was first told that Keisling was on vacation and no one was available. Two days later, when she was told a team would be dispatched, the woman was nowhere to be found, Luby said.

Keisling said that he has a limited number of psychiatrists on his staff. In the past, he said, getting doctors to leave their offices has been a problem that he is attempting to rectify by hiring new people. "You've had people in the system for 30 years who were not used to going out," he said.

Some of the difficulties with shelter operators, he said, have arisen because of confusion over who is responsible for responding to calls. Keisling said he is in the process of working out an agreement with the D.C. police about who should respond. The police, he added, should handle emergencies in which a mentally ill person becomes violent; other calls should go to the crisis unit.

In addition to emergency and clinic services, housing remains one of the most critical unmet needs of the mentally ill.

The city hopes to double the current number of 700 group home beds by 1991. However, advocates say that the city's 203 group homes for the mentally ill are poorly monitored and that their owners are untrained in dealing with mental illness. Furthermore, they say, the District's payment of $14.28 per day encourages the creation of large boarding houses, not the small, family-like residences considered to be more therapeutic.

Group homes are supposed to provide room, meals and other forms of support ex-patients need to adjust to life outside the hospital. Too often, mental health lawyers say, residents are mistreated or left to fend for themselves. Many, especially the elderly, spend their days in numbing idleness.

Last year, several employes of a 104-bed group home with a history of health code violations charged that residents were fed spoiled food and that untrained staff in the lice-infested facility dispensed medication.

Group home operators say they feel vulnerable to economic pressures. "We have no guarantee to fill the vacancies we have, and no contract," said Elanders (Tex) Taylor, president of the 100-member Capitol Association of Community Residence Facilities. "We are at the mercy of the system," said Taylor, who is supposed to provide room and three meals per day and monitor the medication of his clients.

Taylor, a former Army medic, and his wife Diane, a nurse, operate two homes, both in Anacostia. One houses 15 women, who range in age from 60 to 84 and have spent between 30 and 45 years at St. Elizabeths.

"Aren't they cute?" said Diane Taylor, who calls the women "my babies" as she watches them eat, in total silence, a lunch of soup and tuna sandwiches.Some Former Patients Adjust Well

When a full range of services is available, some ex-patients adjust well to life outside the hospital.

Eloise S., 57, a former St. Elizabeths patient who did not want her last name used, is living in a federally subsidized apartment rented by the Green Door, the city's largest day program that helps former patients acquire job and social skills. She regularly attends programs at the Green Door, located in a row house near Dupont Circle. There she chats with other patients, answers telephones and edits the clubhouse newsletter.

Eloise began attending Green Door day programs while a patient at St. Elizabeths. For the first nine months she spoke to no one, sitting in a corner with her head bowed, smoking. After the staff began asking her to run errands, she gradually began talking to other patients. Currently, Eloise, a large, voluble woman, is helping to organize a citywide support group for former mental patients.

"The difference it makes when someone can connect is amazing," said Green Door director Judith Johnson. "Most of our folks have had so many instabilities and rejections. The lesson is to get people out of the hospital and into the community so they can be productive members of society."

Shealia Hughes has not been so lucky. She is still at the House of Ruth. Last week, she won the annual competition for the design of a Christmas card -- a small house in snowy woods -- that will be sent to shelter supporters.

For Hughes, the worst part is the sense of futility that comes from living in a shelter and sleeping in a cramped room with 17 other women whose mental and physical ailments often keep her awake.

"I'd like to have my own place, just a nice little comfortable place," she said. "It's rough . . . when you don't have anything coming in and nothing seems to be progressing."

Articles appear as they were originally printed in The Washington Post and may not include subsequent corrections.