Maurice Hart spends his days on the streets of Washington bundled in a blue plaid summer sport jacket, dark green herringbone vest, red and white checked shirt and green khaki pants. He spends his nights at the Blair School shelter for homeless men in Northeast.
Hart, 28, has been at the shelter since January, when he was released from St. Elizabeths Hospital after a three-month stay. The day he was discharged, he said, "I got orders to come over here."
A few blocks away, Willie Mae Stewart, another former St. Elizabeths patient, lives in a room in a three-story brick row house with a castle-like turret. Green plants line her windowsill, her belongings are neatly arranged, and a sense of dignity pervades the room.
"You got some freedom," the slight, 76-year-old woman said of her home. "I don't care to be in a hospital unless I'm sick."
Hart and Stewart are among the thousands of former mental patients who have been discharged from St. Elizabeths Hospital as part of a court-ordered plan to move patients out of the hospital who are deemed able to live in the community, either on their own or with a bit of help from someone else. They also represent the mixed experiences of those who have been released.
Some, like Hart, end up wandering the streets, "trying," as he said, "to make attempts to get out of just being somebody who's got nowhere to be going." More, like Stewart, have discovered a new and happier life outside the red brick buildings at the sprawling Southeast Washington institution, the federally operated mental hospital for District of Columbia residents.
Thousands of patients have been released from the 127-year-old facility over the past five years as a result of the 1975 federal court order won by the Mental Health Law Project requiring that mental patients here be given "suitable care and treatment under the least restrictive conditions." And thousands more of the hospital's outpatients and inpatients may be released over the next few years to live in the community again and be treated or trained at facilities run by the D.C. government or hired by the city.
The so-called deinstitutionalization of St. Elizabeths' patients, part of the nationwide trend over the last quarter century toward moving patients out of warehouse-like mental institutions and into community-based facilities, has proceeded slowly and fallen far behind the timetable set in the court order signed by U.S. District Judge Aubrey E. Robinson Jr.
But enough patients have been released to indicate that deinstitutionalization is producing a mixture of results. There are numerous success stories of former patients, including some who have been hospitalized for years, who have discovered with the aid of job training and reorientation programs that they can live without a hospital attendant planning their every move.
For some, however, the new life has not been so pleasant. They may have been unable to cope with society's demands and returned to the cloistered confines of St. Elizabeths or they ended up adrift in the anonymous world of the streets.
In the view of Dr. Herbert Pardes, director of the National Institute of Mental Health, the federal overseer of St. Elizabeths, the process of returning mental patients to the community here has been "not too atypical of other large cities."
"Deinstitutionalization has worked unevenly around the country," he added. "Too many have been put out prematurely and people have been walking around aimlessly. Washington is going about it in a much more careful and deliberate way. There are a large number of patients who are out and doing well."
Ideally patients released under the dictates of the deinstitutionalization plan are thoroughly counseled as they leave the hospital, assigned a case manager to oversee their activities and placed in some sort of halfway living and training program, depending on their capabilities. Hospital and city officials say that the large majority of those leaving the hospital and moving into city-run or city-financed facilities are receiving such attention.
St. Elizabeths officials said that attempts are made to track down the hospital's outpatients who do not show up at the hospital as scheduled for counseling or to receive medication. But once the patients are placed on the District's rolls, it becomes the city's responsibility to care for them.
Charles Holland III, the 28-year-old president of a group of 300 former patients now receiving day counseling and job training at the Green Door halfway house, is one person for whom deinstitutionalization has been a godsend. For years he said he suffered from dizzy spells, blackouts and seizures after being hit by a car when he was 8 years old. But he said he did not pass through the doors of St. Elizabeths until he was arrested for possession of cocaine and shoplifting a stereo receiver in 1977.
He said he was diagnosed a paranoid schizophrenic and his counselors say he exhibited marked delusions of grandeur, sometimes claiming to be "president of the world." He said he spent a total of three years at St. Elizabeths. But he was released and charges against him were dropped, he said, when he agreed to enroll in the Green Door program and appear every three weeks at a city mental health clinic to pick up his medicine.
"I felt really calm and natural about returning to the community," Holland said. "I don't think I'm a dangerous type of person."
Now, two and a half years after enrolling in the Green Door program, Holland is seeking a maintenance job and has a distinct appreciation of the difference between the place many call St. E's and life on the outside. "At St. Elizabeths," he said, "there's always someone to watch you, feed you. Here you learn to do for yourself. It's better than a maid or a butler."
But not all former patients are as fortunate. When about two dozen patients were leaving the hospital in December and early January, St. Elizabeths officials simply called workers at the Blair shelter, located at 6th and I streets NE, and asked if they had room for the people they were releasing, according to shelter officials.
Dr. Bernard S. Arons, who heads the deinstitutionalization effort for St. Elizabeths, said, "It's been our experience that people are not sent to the shelters as a long-term living arrangement." Nonetheless, he conceded that "it's clear that some people go from here to the shelters."
He said hospital officials believe that most of the former patients who regard the shelters as home have not been ready to be discharged from the hospital, but rather have demanded--as is their right in most cases--to be released. In such instances, he said, a treatment plan is given the departing patient, but it is largely up to the patient to follow it.
No one knows with any certainty how many of the city's estimated 5,000 homeless are former St. Elizabeths patients. But John Dillingham, director of the Metropolitan Mental Health Skills Center, said he thinks that from 1,000 to 2,000 of them may have a major mental illness.
Michael L. Ferrell, director of the Blair and Pierce shelters for homeless men, said that of the nearly 300 men who show up nightly for a shower, a free meal and a warm place to sleep, about 100 "need some kind of mental health care."
"What we are finding is that some of them are hooked into some kind of [mental health] support system," Dillingham said. "Most of them are not. They've lost contact with the support service or with St. Elizabeths. The number who have fallen through the cracks is far greater."
Dillingham was talking about people like Maurice Hart, a man Arons said "basically left on his own." Hart said that as he left the hospital, officials mentioned a couple of places where he might stay, including the shelter. At one other place, which Hart remembered only as a home in Northwest Washington, he said, "They told me I could stay as long as I wanted. But I would have had to get some money--over $300 a month--and I didn't have enough."
Now, Hart's life and thoughts are disjointed and the uncertainties abound. One moment he said he preferred being away from St. Elizabeths, the next, he said, "I'd rather be in St. Elizabeths. There's not a lot to do outdoors."
Arons said St. Elizabeths officials also "feel he ought to be back in the hospital."
A Happier Life
Compared with Hart's anxieties, Willie Mae Stewart has no doubts about where her life should be spent. She's excitable and tart-tongued, but cares for herself to a large degree. She also is quick to admit why she landed in St. Elizabeths: "I got to fighting and I broke a woman's arm [with] a good seasoned oak stick. She messed with me, interfering with me."
That was in 1969 and Stewart has been in St. Elizabeths several times since then, as well as a handful of foster homes.
St. Elizabeths, she said, "was like a second home. Anything I needed, they kept giving it to me."
Still, would she rather be in St. Elizabeths?
"You got to be joking," she responded instantly. "You know I don't want to be on a ward."
At St. Elizabeths, she recalled, "You get up at 6 o'clock and go to bed at 8:30 or 9. Here if I want to stay up to 10, I can.
"I walked down to the bank and cashed my check," she said of one recent day's activities. "I went to the Safeway and shopped. When I get tired of sitting around, I get some clothes on and go downtown."
Other former St. Elizabeths patients voice similar sentiments about their new-found freedom. William M. Dixon, the 72-year-old former District resident who is the lead plaintiff in the suit that led to the court-ordered movement of patients from the hospital, has been confined to a wheelchair since 1953. But he still has found his life at the Clinton Convalescent Center for the last four and a half years far less confining than the 16 years he spent at St. Elizabeths.
"Everyone is entitled to their freedom," Dixon said in his halting speech. "Everyone is cooped up in the ward and they say they'll feed them until they die. I don't think that's right."
Perception of Others
But for Dixon the most significant difference between living at St. Elizabeths and living in a nursing home is the simple perception that others may have.
"When you were in a hospital," he said, "they say you were crazy. In a convalescent home, they say he lives there. That's a big difference."
Danette Bennings, 20, found herself at St. Elizabeths for eight months in 1979 after suffering a nervous breakdown. "I was in high school at the time," she said. "There was a lot going on, shootings and dope. I got involved in the wrong group. They put down I was a schizophrenic. I never tried to kill anyone or hurt myself."
She's been back for one- or two-month stays at the hospital three times since then, but now feels that with the training program she's enrolled in at the Green Door she's slowly reassembling the pieces of her life. She works the cash register, sorts and prices clothes and picks up after customers at the Green Door's thrift shop on 18th Street NW.
"It's work that makes you face up to reality," she said. "It helps you rehabilitate yourself, to pace yourself. They're going to be sending me to a transitional living unit soon. I hope to get a job, maybe as a secretary."
It is such mixed results of deinstitutionalization and the delays in implementing the court order that now lead hospital officials to say that eventually some rethinking about the effort will have to be done.
"As we look now," Arons said, "it could have been expected. It's a hard thing to do to not let people go until there are facilities available."
A total of 93 percent of the hospital's patients are released within a year of their admission, an increase from 78 percent five years ago. But Dr. William H. Dobbs, St. Elizabeths' superintendent, said that for many long-term patients the transition from hospital to community is a difficult one. "We have patients who have been here up to 49 years," he said, including 70 over 80 years old who have been at St. Elizabeths 30 years or more. "This is their home here at this point."
Moreover, Arons and Dobbs said that numerous patients simply do not want to leave the hospital and do everything in their power to thwart efforts to transfer them to a new life in the community, often times engaging in bizarre behavior to demonstrate their lack of readiness to be moved. "Someone will get upset and start shouting or pick up an ashtray and throw it," Arons said.
The hospital has started one program specifically designed to treat patients who have made several unsuccessful attempts at moving back into the community. Arons said it is likely that many of these patients will be long-term St. Elizabeths patients "until there are nursing homes who will take psychiatric patients."
Nonetheless, the movement of patients out of the hospital is continuing and the Mental Health Law Project is adamant in its belief not only that deinstitutionalization can work but that there should be no slackening of the effort.
"We are concerned," said Margaret Ewing, a lawyer for the group, "that none of the obligations in the court order be neglected."