Paul opens his mouth to answer, and at first, nothing comes out. He would rather not think about these things again. His hands begin to shake, and he experiences a shiver, as if he is feliving some long and cold night on the streets. Wasn't it great when he was told, after four years, that he no longer needed to be a patient at St. Elizabeths Hospital? Wasn't it great to be back on the outside? He knows what the answer could and perhaps should be. He would love to say yes. He can't.
He was a victim of what is a major national problem -- the poor follow-up care for chronically mentally ill people who are no longer institutionalized. He was told to report regularly to an outpatient clinic at D.C. General Hospital. He lacked the will to do that on his own, and mental health workers, even if they wanted to force him into treatment, were not legally empowered to do so unless they sought to have him involuntarily committed. One St. Elizabeths official says that was unlikely because the city has a mental health care management system "that does not seem to work well now" and adds, "There is not a good feeling that they are providing personal service now."
But the problem is bigger than that. Other sources of help that could heen there were not. His father refused to let him live at home. The stigma of "being crazy" alienated his friends. He wound up homeless, "eating at soup lines, begging for money, sleeping anywhere I could -- abandoned cars, abandoned houses."
Too many would have seen Paul on the "turf" he staked out: a set of steps to a church at New York Avenue and 14th Street in Northwest, where he begged and slept on warm nights and believed that he would have come to such an end whether the mental health care system or charitable groups or people had reached out to him or not. But Paul was fortunate the steps he had chosen to claim as his own were those of a church that welcomed patients from St. Elizabeths every Wednesday night to socialize with them, play bingo and cards, to sing, to give them a "normal" set of people they could "connect with." They welcomed Paul, too, and that welcome, for one who had been living on the streets and believing no one cared, was overwhelming.
"I was off balance. You don't even know how to say, 'Thank you.' You have been down and out so long. You just see it as a blessing, by the grace of God," Paul said. "Sanctuary, that's what that place is."
The church, New York Avenue Presbyterian, signed him up for the Social Security checks he was entitled to, and allows him to do maintenance work around the building on a voluntary, nonpaying basis. It has even given him his own bedroom in a house it runs for formerly homeless men. Now Paul talks about getting married, having four children. He has applied for a job at the U.S. Postal Service. His story is important for many reasons.
By 1988, funding and responsibility for St. Elizabeths Hospital will pass from the federal government to the District government. At the same time, the city will be shifting from an institutional, inpatient treatment system to an outpatient, community- based treatment system. The outpatient and intensive treatment caseload for adults is expected to be 4,500 in 1988 and 9,500 in 1991. This will be a tremendous responsibility. With what assurance are we told that the city is up to it?
District officials can grasp the concept called "surrounding," in which churches, community groups, schools and charitable organizations assume an active role in helping the previously institutionalized assume a more independent life. But that kind of network is not in place. It needs to be anchored by an effective mental health care system, and that is not in place either.
"The point is that there are other Pauls who need to be picked up and who require adequate housing. You must find someone to follow through and give them the connections they need to make it," said an official at St. Elizabeths. It is a choice between more and more disoriented street people and people who, with help and support, can lead more constructive lives. The time to prepare rapidly for that is now.
"I'm just another individual who's sick and trying to get better," Paul said. "You need help to do that."
Where will it come from?