Mental Health Survey Report

Coalition on Homelessness (coh@sfo.com)
Mon, 14 Jun 1999 11:56:57 -0800


Dear Tom,
The following is a report released by the Coalition on Homelessness, San
Francisco on June 10th.  Included is the actual survey instrument we used,
in case any other homeless agency would like to do a similar survey in
their location.  Feedback is welcome!

Peace,
Chance Martin
Coalition on Homelessness, San Francisco

P.S. Please check out our url:
http://www.sfo.com/~coh

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THE VOICES OF HOMELESS PEOPLE WITH MENTAL ILLNESSES

LOCKED OUT

A REPORT BY THE COALITION ON HOMELESSNESS, SAN FRANCISCO
SUBSTANCE ABUSE MENTAL HEALTH WORK GROUP
JUNE 10, 1999

A big warm thank you to all the righteous volunteers who made this study
possible.

Survey Takers:
Jane Kahan, Bert Connell, Chance Martin, Allison, Laurette Spanglet, Pattie
Yost, Frank Vallecillo, Ronnie Eagles, Hal Garner, Jack York, Mike Wise,
Bill Hirsh, Mara Raider, Johnnie Durden, Patricia Knox, Jennifer
Friedenbach, Mark Williams, Lionel Kelly

Writers:
Laurette Spanglet, Allison, Chance Martin, Marykate Connor, Jane Kahan,
Jennifer Friedenbach

Technical Assistance:
Dr. Harvey Feldman, Tia Martinez


TABLE OF CONTENTS:

Executive Summary


Introduction


Methodology

How the Survey was Conducted
Who was Surveyed

Experiences with the Mental Health System
Access
Ever Tried to get into Treatment
When Tried to get into Treatment
Length of Treatment
Negative Experiences
Positive Experiences

Mentally Ill People Want Treatment

Conclusion


Appendix


EXECUTIVE SUMMARY

The Coalition on Homelessness, through its Substance Abuse Mental Health
Work Group, interviewed 282 homeless men and women at shelters, self-help
centers, food lines, drop-in centers, health clinics and welfare offices
during the months of April and May in 1999. The survey was primarily
conducted by volunteers who had themselves experienced mental illness and
homelessness. This survey was done to gain insight on the mental health
treatment system from the perspective of homeless people who have mental
health issues.

Mentally Ill Homeless People Want Treatment-

224 or 92% of the people who responded said that if a program was designed
that met their individual needs, they would enter it.

One Third of Those Who Tried To Get Services Didn't Get Them-

When we asked our survey respondents if they had ever tried to access
mental health services in San Francisco, 152 responded 'yes' (63% of
respondents). Of the 152 people who attempted to voluntarily access
services, a shocking 47 or 31% never got any.

People Keep Trying To Get Treatment-

37% (93) of those who had tried to access services, tried in the last year.

Of the 105 respondents who did manage to get mental health services, 25 or
24% of respondents received treatment for less than a month. An additional
26 or 25% of people were in treatment for 2 - 6 months. Comparatively, only
24 people or 23% received treatment for more than ten years

Treatment System Fails More Then It Succeeds-

More then half (51%) reported a negative experience with the mental health
system.

Of the people who specified a negative experience, the most common comment
was that the process for entering treatment was too cumbersome and that it
took too long. Other common reasons were negative interactions with staff,
denied medications, denied treatment, or kicked out of treatment.

Mentally Ill Homeless People Know What They Want-

Housing (179 or 63%), counseling (171 or 61%), and medication (148 or 52%)
were cited as the top needs in treatment services.

Respondents were asked what would be contained in their ideal program.
There were fifty seven (57) comments wanting staff that would be caring and
respectful.

Fifty-seven (57) participants also wanted to have treatment available on
demand. Respondents in this category said the ideal program would have easy
access, would serve them right away without a wait, or without being turned
away. They didn't want a bureaucratic process that prevented them from
getting the help they needed.

The third category of common responses for an ideal program was those that
fell under the productivity category. Thirty-five (35) respondents called
for a program that included work, recreational activity or some way to give
back to their community.


INTRODUCTION

San Francisco states in its federal HUD report that the estimate of
homeless men, women, and children exceeds 14,000. About 30% of those are
mentally ill, often the most visible segment of the homeless population.
They are seen everywhere - pushing shopping carts, sleeping in doorways, or
asking for spare change.

This survey was done by the Coalition on Homelessness Substance Abuse
Mental Health Work Group to get the perspective of homeless people with
mental illnesses and to create a dialogue for understanding each
individual's experience within the mental health system in San Francisco.
We attempted to gain insight on the ideal mental health treatment program
from each person's individual perspective. We wanted to ensure the voices
of homeless people who have mental health issues are heard loudly and
clearly.

Mental illness itself continues to be highly stigmatized. People suffering
from this condition are often ignored and misunderstood. The result for
many has been homelessness, poverty and destitution.

The voices of those we interviewed were articulate, lonely, desperate, and
most of all, ringing clear. While individuals had diverse and varied needs,
it was apparent that each person knew exactly what they needed to get
healthy and off the streets. In order for the City to succeed in assisting
individuals, policy makers must stop and take the time to listen. Until the
needs of people, not funding, are placed at the center of the system, the
system will fail.

If the City funds and creates programs based on people's needs, then
treatment will be successful and the City will not incur the higher costs
associated with untreated mental illness. Untreated mental illness often
leads to higher hospitalization, social service, lost productivity and
unnecessary criminal justice costs.

We need a community based mental health treatment system that not only
treats clients, but treats people who become clients with dignity and
respect.

It's time to tear through the silence.


METHODOLOGY

It is important to note that these responses are not meant to represent a
scientific survey, rather they are a reflection of what 282 homeless people
with mental health issues want and need. There were many individuals who
were not able to respond to the survey, because their psychiatric
disabilities were too severe. These are the same people most often
neglected by the treatment system. In addition, there are populations that
are not represented here, such as Pacific Islanders, and others that are
underrepresented, such as Latinos.


How the Survey Was Conducted-

Mental health issues are highly stigmatized, and as a result this was a
very difficult survey to undertake. We spent a great deal of time designing
the survey in a way that we could gather the information we needed, while
being deeply sensitive to the nature of this particular issue.

The survey was peer based with survey takers being people who have mental
health issues themselves and who are or had been homeless. Surveyors
targeted sites where people without housing congregate, although very few
sites contained people who suffered exclusively from mental health issues.

Part of the survey design was to never directly ask people if they had a
mental health issue prior to interviewing them. Instead, we let people know
that the purpose of the survey was to gather information from homeless
people about their experiences within the mental health system. At that
point, many individuals self identified as not having any illnesses,
whereby the interview was terminated. We then used indicator questions to
determine if someone had a mental illness, and discarded those surveys in
which no mental health condition was indicated. This led to the elimination
of 36 additional surveys, which left us with 282 usable surveys.


Who was Surveyed-

We completed surveys during the months of April and May, 1999. Surveys were
conducted at shelters, self-help centers, food lines, drop-in centers,
health clinics and welfare offices.

Total Sites & # of respondents at each:

Mission Rock Shelter		72	(23%)
Streets			11 	 (3%)
Tom Waddell Health Ctr	40 	(12%)
United Council Food Prg	8	(2.5%)
St. Anthony's Food Prg	26	(8%)
Glide Food Program		8 	 (2.5%)
GA Office			29	(9%)
Mission of Charity Food	7	(2%)
Central City Hosp. House	20 	(6%)
St. Anthonys Women Sh	5 	(1.5%)
Haight Ashbury Food Prg	24 	 (7%)
Public Library		5 	(1.5%)
Episcopal Sanctuary Shltr	16	(5%)
Senator Res. Hotel		4 	(1%)
MSC-S Shelter		14	(4%)
Spiritmenders Drop-In	4 	(1%)
McMillan Drop-In Ctr		13	(4%)
Swords to Plowshares 	2
A Women's Place Shltr	13	(4%)
SFGH			1

The age of the respondents had a wide range, from 15 years of age to 84
year old. The majority of homeless people surveyed were between the ages of
36-50 years old; this group comprised 50% of the homeless people we spoke
with. The remainder were almost evenly divided into 15-30 years old (32 or
11%) and 51 and older (51 or 16%).

Age of Respondents:

15 - 20		4		46 - 50		54
21 - 25		8		51 - 55		27
26 - 30		20		56 - 60		13
31 - 35		43		61 - 65		8
36 - 40		57		66 - 70		2
41 - 45		56		70 +		1


The ethnicity of the respondents is as follows: There were 106 Caucasians
(37%), 98 (35%) African-Americans, 16 Native Americans (6%), 14 Latinos
(50%), 11 Asians (4%), and 10 (3.5%) mixed ethnicity, with the remainder as
unknown/unspecified.

We interviewed 172 males (61%), 91 females (32%) and 8 transgenders (3%),
and 11 unknown/undecided (4%).


EXPERIENCES WITH THE MENTAL HEALTH SYSTEM


"I was suicidal and didn't get any services. I could have been dead." - 47
year old Asian Male

We asked respondents if they had ever tried to get into the mental health
system and if so, what positive or negative experiences they had with the
system. While the answers were quite varied, there were some clearly
startling findings.


Difficult Access a Major Problem -

Access is the essential component in the delivery of mental health services
to a population which is largely characterized as 'difficult to engage',
and access is the biggest barrier for poor and homeless people seeking
mental health treatment.

When we asked our survey respondents if they had ever tried to access
mental health services in San Francisco, 152 responded 'yes' (63% of
respondents). This also indicates there is a need for engaging outreach to
the pool of people who need mental health treatment but haven't tried to
access it for whatever reason.

Of these 152 people who attempted to voluntarily access services, a
shocking 47 or 31% never received any. Men were significantly less likely
to be able to access services, as 36.7% of men never received services
after trying, compared to 18.2% of women. Of the age groupings, youth were
the least likely to access services.

Ever Tried to Get Into Treatment:

Yes		152 (63%)
No		128 (37%)

We also asked people when they last tried to get into treatment. Of those
who responded, a surprising 93 or 63% had attempted within the last year.
This indicated that people have not given up hope, and are actively trying
to enter treatment. 26 (17%) had tried one to two years ago, while those
remaining tried three or more years ago.

Last Time Tried to Get Into Treatment:

Less then one year from time of survey	93 	62%
1 - 2 years ago			26	17%
3 - 6 years ago			16	11%
7 - 9 years ago			 4	 3%
More then 9 years ago		 9	 6%

Centralized intake procedures can often fail to accommodate homeless
people's ability or inability to keep vital mental health appointments.

"The appointment was too far away and I forgot and never went back." - 41
year old African American female

"I was not able to get an appointment, as the person referring me stayed
unavailable and eventually I got disgusted." - 36 year old African American
male

Access to an adequate range of mental health services is an obstacle for
those who are involuntarily committed as well, reflecting the critical
burden on San Francisco's overcrowded psychiatric emergency services.

"I was arrested and taken to the psych ward and turned loose the next day
with no referral for continued care." - 34 year old white female


Inadequate Treatment -

Of the 105 respondents who did manage to get mental health services, 25
(24%) respondents received treatment for less than a month. After
navigating the difficult process to receive treatment, and then to only
receive it for a month is neither beneficial to the individual, nor to the
health of the City at large. An additional 26 people (25%) were in
treatment for 2 - 6 months. This indicates participants are not receiving
the long term treatment necessary to address their mental health issues on
a continuous basis.

The remaining respondents received treatment from 7 months to nine years,
with 24 (23%) people having received treatment for more then ten years.

How Long Were You In Treatment?

Never Got In		47	30%
A month orless		25	16%
2 to 6 months		26	16.5%
7 - 12 months		13	8%
1 to 3years		10	6%
3 - 6 years		10	6%
7 - 9 years		2	1%
10 years or more		24	15%


More Than Half of Respondents Had Negative Experiences -

We asked people what their experience was with the mental health system.
Sadly, more then half (51%) reported a negative experience with the mental
health system. This is clearly an unacceptable level of dissatisfaction
with a badly needed city service. There were dozens of reasons why people
said they had either a positive or negative experience with the mental
health system, which indicates we need diverse and effective treatment
services to meet the varied needs of today's San Francisco.

Positive vs. Negative Experiences:

Negative Experiences	104*	51%
Positive Experiences		 99*	49%

*Please note respondents could have multiple experiences and both positive
and negative experiences

"The Psychiatrist broke confidentiality and damaged my credibility to get
my children back" - 44 year old African American female

Of the people who specified a negative experience, the most common comments
were that it was too cumbersome of a process to access services, and that
it took too long.

"I was trying to get back on medication and they gave me the run-around,
and I wound up back in prison" - 44 year old African American male

Of those who specified how the experience was negative, the second most
common reasons were that they had bad interactions with staff, were denied
medications, denied treatment, or were kicked out of treatment.

"I was asked to leave because the Psychiatrist said I was a trouble maker.
I was trying to let people know what their rights were." - 47 year old
African American male

"The City Clinic treated me like a criminal for seeking mental health
services" - 37 year old white male

Most Common Reasons For Negative Experiences:

Denied Meds/Treatment			9
Bureaucratic Process			8
Bad Experience with Staff			6
Kicked Out of Treatment			5


Less then Half of Respondents Had a Positive Experience -

People had positive experiences with the mental health system as well.
Staff/client relationships also played a large role in survey respondent's
positive experiences. Of those who specifically described the positive
experience, the most common response was that they liked the talk therapy
(7). Also, numerous people mentioned programs that got them off the streets
where they were able to deal with issues, and it was a safe and comfortable
environment. This leads us to believe, that if done right, treatment does
work.

"Treatment made me a better person, better outlook on life by helping me to
deal with people in a more positive and progressive way. " - White male of
unknown age

Most Common Reasons For Positive Experiences:

Talk Therapy			6
Safe and Comfortable Environment	4
Empathetic Staff			3
Able to Deal with Issues		3
Medication			3


UNTREATED MENTALLY ILL HOMELESS PEOPLE WANT TREATMENT

Clearly, homeless people in San Francisco have diverse needs, as
demonstrated by respondents describing what they felt an ideal mental
health treatment program would be like. The results from this section of
the survey indicate that people know exactly what kind of treatment works,
what services they need, and how exactly they need to improve their health
and exit homelessness. Listening to individual voices and building a system
around the ideas and visions of homeless mentally ill people themselves is
critical if we are to truly provide effective treatment.

Homeless people are often shunned and ignored by society at large. When we
add to that the portion of homeless people who are mentally ill, we have
one of the most vocally despised groups in our society at large. People
with mental illnesses often have their opinions disregarded as "crazy", and
are not perceived as being able to know what is best for themselves. The
following results dispel that notion. Mentally ill homeless people know
exactly what they need and what works.

Ideal Program-

Homeless mentally ill people were asked what their ideal mental health
program would be like. The responses were nothing short of stunning, and
obvious in the face of the need.

"An ideal program would have people who don't treat you like crap because
you're a drug addict" - 41 year old white female.

The most common responses centered around the kind of staff the program
would employ. After all, programs are made up of people, and programs are
only as good as the people who work there. There were fifty seven (57)
comments about the kind of staff that would be in their ideal program. In
their own words, people wanted staff who are "dedicated, friendly,
supportive, sympathetic, caring, patient, loving, non-judgmental, calm, and
serious. " There were calls for staff who had good time management skills,
who knew what the respondents needed, who are at the "same mind level" and
who would take the time to develop relationships with their clients.

"The ideal facility would have counselors that are caring and sympathetic,
less apathetic" - 47 year old African-American woman

For 57 participants, the ideal program would have treatment available on
demand. Respondents in this category said the ideal program would have easy
access, would serve them right away without a wait, or without being turned
away. They didn't want a bureaucratic process that prevented them from
getting the help they needed. These responses demonstrated that people in
crisis should not be turned away and told to wait.

The third category of common responses for an ideal program was those that
fell under the productivity category. Thirty-five (35) respondents called
for a program that included work, recreational activity or some way to give
back to their community.

"An ideal program would enable people to work and become independent. It is
one which would not treat patients as dependent and helpless" - 50 year old
Native American woman.

Thirty-three (33) people said they wanted programs that were attached to a
integrated set of services, such as hospital services, substance use
treatment, dental care, follow-up and assessment. Twenty (20) people said
the ideal program would include self-help or peer support, which consumer
advocates have been urging for years. These included comments around
self-government, and how beneficial it is to receive help and then return
that help to people in similar circumstances. People wanted to develop
support systems and friendships. Homeless people with mental illnesses
would like to see their peers when they come for services -- it's
reassuring and empowering.

Thirteen people (13) said they wanted a comfortable, safe environment for
services to take place in. These individuals emphasized both ambiance and
feelings of safety within programs.

Many respondents (12) wanted targeted services. They would like to see
programs that target particular communities, such as women, seniors and
youth. Significantly more women targeted services, as 14% of women
requested this, compared to only 3.7% of men.

"Give us a place to live, clothing, and food and therapy" - 50 year old
African-American woman.


Most Common Responses to Ideal Program:

Dedicated and Friendly Staff			57
On-demand/Easy Access & No Turnaway		57
Work and Recreation				35
Integrated Services				33
Subsistence Services			21
Peer Support/Self-Rule			20
Comfortable and Safe Environment		13
Individualized Services			13
Targeted Services				12


Mentally Ill Homeless People Know What Services They Need -

Respondents were asked what services they would want in an ideal program.
Almost all wanted comprehensive services, so that their needs would be met
in a holistic manner. They felt the other needs in their lives were
intimately connected to their mental health; in other words, they felt that
a stable living situation was a prerequisite to managing their psychiatric
issues.

"Don't put us in shelters, give us housing." - 52 year old African American
female

The number one item requested was for housing. One hundred seventy-nine
people (179 or 63%) requested this. Many people saw housing as integral to
their overall mental health and ability to become productive.

"Without housing people can't find work. This is the most serious problem.
And without money, people can't find housing because of the high rents" -
37 year old Asian male.

The second highest request was for one-on-one counseling. One hundred
seventy-one (171 or 61%) respondents said the ideal program would offer
this service. An additional one hundred forty (140 or 52%) people said the
ideal system would offer group counseling. This was a theme throughout the
responses - people want someone to take the time to listen to them, and
assist them in addressing their issues.

The third highest request was for medication, with one hundred forty-eight
(148) people saying the ideal system would offer medication. And one
hundred thirty-eight (138) individuals said the ideal program would offer
therapy. In summary, housing, counseling, and medication are the top needs
for services in the ideal mental health system.

Top Services Mentally Ill Homeless People Want:

Housing				179		63%
One on One Counseling		171		61%
Medication			148		52%
Group Counseling			140		50%
Therapy				138		49%
Diet and nutrition			137		49%
Job training and Placement		128		45%
Health Care			125		44%
Substance use Treatment		120		43%
SSI Advocacy			114		40%
24-hour services			110		39%


Mentally Ill Homeless People Want Help -

Perhaps the most important finding of our survey is that mentally ill
homeless people want treatment. This is an especially compelling finding
given that the dominant message we hear in the media and from certain
politicians is that homeless people with mental illnesses simply don't want
any assistance. 92% of the people who responded said that if a program was
designed that met their needs, they would enter it. Many gave reasons why
they would enter it, including that they needed the help, that they felt
they could help others in their ideal program, and that it would be
beneficial overall. For the small number of people who would not enter an
ideal program, they said they didn't need mental health treatment at this
time, or they were already in treatment.


CONCLUSION

This survey provides us with an extraordinary wealth of information. The
findings are revealing, informative and at times shocking. We must no
longer ignore the needs of people suffering from mental health issues - it
is high time to both expand and reform the mental health treatment system.
The voices that come through in this report are calling for action, and as
a community it is our obligation to respond. We cannot afford to wait.

The Coalition On Homelessness Substance (Ab)Use Mental Health Work Group
(SAMH) will be looking to this survey to direct our advocacy efforts. We
will continue to urge responsibility on the part of policy makers in the
position to create real change for mentally ill homeless people.

============================================================================== A
PPENDIX: Mental Health Survey

#0)	SITE _________


Hi. My name is ______________, and I am from the Coalition on Homelessness.
We are gathering input from homeless people on what kind of mental health
services they want and what changes they want to see happen to city mental
health services. We will then present this information to the City and use
this information in our work to change the system. This is confidential,
anonymous and we are not asking your name.

1. Have you ever tried to get mental health services in the past?

	1___yes

	2___ no (Skip to question 5)


2. When was the last time you tried?

	mo/yr ____


3. Approximately how long were you in treatment?

	#years/ #months _______


4. What was your experience with it, either positive of negative?


5. If you were to design an ideal program to help people who want mental
health services, what would it be like? (Record narrative here and on back
of survey)


6. What types of services would it offer? (Check all that apply)

1___ Assessment			11___ Life Skills

2___ Childcare			12___ Medication

3___ Case Management		13___ Psychiatric Treatment (therapy)

4___ Counseling - Group 		14___ Parenting

5___ Counseling - One on One 		15___ Peer Counseling

6___ Diet and nutrition		16___ Recreational Activity

7___ Housing
				17___ Substance Use Treatment

8___ Health Care			18___ SSI/ Benefits Advocacy

9___ Hygiene			19___ Socialization

10___ Job training & Placement	20___ 24 hour services

21___ Other	(Please Describe)	________________________


7. If a program such as you described were available, would you enter it?

1____ Yes, Why? (record below)

2____ No, Why? (record below)


8. How old are you? _______


9. What race do you consider yourself?

1___White	4___ Mixed Heritage		7____ Native
American/Indigenous

2___Latino	5___ Asian		8____ Other

3___ Black	6___ Pacific Islander


10. Sex: (check appropriate box)

1____ Male 2_____ Female 	3____ Transgender 	 4____ Other

Thank you!
--------------------------------------------------------------------------------
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Record answers to question 4 here

Positive Experiences:

Negative Experiences:

Record answers to Question 5 here and on back of survey:

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