Susan Fox was in her mid-30s before she began to deal with the anxiety and depression that had haunted her all her life. By outward appearances, she was a happy, successful young professional “with a condo, an expense account and a nice car.” Privately, she was hooked on cocaine and booze.
After years of trying to control her addiction, a new job triggered the familiar cycle of stress and relapse. She lost 30 pounds in three weeks and wrestled with insomnia before finally seeing a doctor. Diagnosis: anxiety. Though that was only half the equation. When she moved to Seattle from Washington DC in 1990, the pressure bore down on her again and Fox began to see her symptoms for what they were: depression.
“I remember thinking, ‘I don’t want to be mentally ill,’” she says. “I had this biochemical condition in my body that was probably genetic, and that alcoholism probably exacerbated, and when the alcohol was gone and the cocaine was gone, I was left with this biochemistry and no self-confidence or sense of myself.”
Now Fox spends her days sharing her story in her role as the Executive Director of Peace for the Streets by Kids from the Streets (PSKS), a shelter which offers support programs for homeless youth in the Seattle area. Fox was never homeless, though she came close — bouncing between family members’ couches in her darker moments — and she is well aware of the numbers of homeless youth who have experiences similar to hers.
Homelessness and mental illness have long been linked. Mental illness is especially challenging to treat when it afflicts homeless youth who are ill equipped to recognize or cope with its symptoms. One-half of all cases of chronic mental illness begin by age 14; three-quarters by age 24. Homeless youth exhibit psychiatric disorders at a rate six times higher than the general youth population, according to a 2009 study from shelters in Denver.
The results of early-onset mental illness can be devastating. Consider, for instance, that the National Alliance for Mental Illness (NAMI) reports 70 percent of young people in juvenile detention have been diagnosed with at least one mental health condition. Twenty percent have a serious mental illness.
Their mental illness could be the result of a chronic condition presenting itself, or a ripple effect of childhood trauma. Either way, for teens already struggling to navigate young adulthood, a diagnosis can send them spiraling into an identity crisis, unsure where their selves begin and their conditions end.
PSKS is unique in that it was founded and is organized by the very young people who use its services. At the heart of operations is a governing body of homeless and at-risk youth who help structure the organization’s goals and mission statement. Fox emphasizes that PSKS is not a mental health treatment facility. Like many youth clinics and shelters, it relies on a small volunteer staff to tackle an issue (mental illness) that is gargantuan. How do you help a young person who may not know where his or her next meal is coming from? How do you provide a continuum of care despite the chaotic nature of life on the streets? How do you shield someone from the very triggers that homelessness perpetuates?
Fox says psychological issues are both catalysts for and consequences of homelessness. Young people who live on the streets are more likely to be victims of sexual assault and are often exposed to high rates of violence. They may also be dealing with childhood trauma or depression. Many more street youth show some signs of Post-Traumatic Stress Disorder (PTSD).
“These kids survive in incredible ways,” says Fox. “They could be looked at as mentally ill, but to me, they’re surviving.”
Three years ago, the staff at YouthCare, which runs an emergency shelter and various job and welfare programs for homeless youth in the region, began to notice a huge demand for mental health services. Though YouthCare staff had long known mental health and chemical dependency were barriers to finding housing and employment, they had never tackled it with the intentionality it required, says Hedda McLendon, Youthcare’s former Director of Programs: “We realized this was not our area of expertise. … And we wouldn’t meet need just by adding to our staff.”
To help address the need, YouthCare turned to Ryther, its partner of more than 30 years. Ryther specializes in providing behavioral health services for children and their families. YouthCare clients had been using Ryther’s housing facilities and its chemical dependency counselors. But some 18 months ago, YouthCare began hosting Ryther staff in its residential facilities, such as the Orion young adult shelter in downtown Seattle. McLendon calls this switch an “intentional partnership.”
Ryther’s team — three child psychiatrists and four licensed psychologists — with the help of YouthCare, enrolled about 100 young clients within the first year. Instead of the usual 45-minute treatment sessions, Ryther therapists are embedded in YouthCare’s residential environment. Two work at the Orion young adult shelter. Ryther staff also attend YouthCare meetings and work closely with its case managers. Both organizations understand the importance of delivering care on their clients’ terms and turf. That may mean sessions at a coffee shop or while strolling around the block.
“A lot of kids who have been through the system are a little jaded,” says Karen Brady, Ryther’s Chief of Child Welfare Services. “This [embedded approach] allows us to put a face to them and to see them in a more casual environment before that relationship gets off the ground.”
Brady remembers a young man her staff first connected with through the Orion Center. He seemed distant at first and reluctant to engage. Though it was wintertime, he insisted on sleeping outside the shelter, in a box. Sometimes he came for meals, but he rarely ate. Shelter staff knew he was abusing a variety of drugs. They encouraged him to connect with a case manager. “We spent hours chasing this young man around,” said Brady, “trying to encourage him to have a relationship with us, to have a cup of coffee.”
When their initial efforts failed, staff from YouthCare and Ryther considered contacting the police. Eventually, a case manager convinced the young man to visit a hospital, where he was stabilized and diagnosed with schizophrenia. Meanwhile, staff worked to reconnect him with family members, who had since moved out of state.
“We kept our hands on him and kept him stable until we could get him connected again with family,” said Brady. They did it despite a developing psychiatric condition “that could have cost his life.”
Too often, service providers have to connect young people with other agencies if they have needs that go beyond the first-response agency's programming or capacity. But YouthCare’s partnership with Ryther puts more jointly-offered services under one roof — and keeps fewer kids from falling through the cracks.
“This is not the way it tends to work between social services,” says Youthcare’s Hedda McLendon about the collaboration. “We don’t often get to be in the same room together, thinking about our client and what needs to happen.”
Neighborcare’s Charlotte Sanders is quick to caution against stereotypes; not every homeless person is mentally ill, on drugs or a criminal. Unfortunately, she says, it’s difficult to manage life, let alone mental illness, medication, etc., without a stable place to live. A single slip, such as going off meds, can lead to lapses in judgment that may result in a visit to the ER or run-ins with the law. Though social workers and staff may foresee such an episode, they are generally powerless to intervene.
“Trying to get the system to respond, to get a kid hospitalized or evaluated or to get police to react, is very difficult,” says Brady. “It’s not a crime to be homeless. The folks at Orion do amazing work but they don’t have the ability to [do everything]. Involuntarily hospitalizing somebody for their own benefit is very complicated and there is a shortage of beds in the state.”
The surge in mental health issues among the young homeless population may be a lingering effect of the recession: Many safety net services are still being rebuilt and a growing number of young people who seek those services report that their families are homeless. But it may also be the result of pervasive drug use on the part of homeless youth, as well as the kinds of drugs they’re abusing.
“If somebody has a preexisting condition, chemical dependency complicates it,” says Brady. “The availability and the type of drugs on the street are very different from when I was a kid. It exacerbates the trouble the kids are already having.”
The Affordable Care Act (ACA) is helping, says Brady. Increased access to health care is changing the way shelters for homeless youth dispense services. For example, Obamacare now provides coverage for young people, 18 and older, who previously were ineligible for Medicaid unless they were pregnant or parenting. A trip to the emergency room is still pricey, but ACA coverage helps to avoid those expensive crisis services. It also covers young people after they age out of Neighborcare programming at 23.
“Before, homeless people were often just going to the emergency room,” says Susan Fox. “They probably still are. But now they can be covered by health insurance.”
Affordable healthcare notwithstanding, Fox believes the best way to help homeless youth who are wrestling with trauma or mental illness is to take mental illness out of the shadows. “You and me, we have our private shrink and our private doctor, so we can keep our secret about our depression or bipolar disorder,” she says. “… But we will not have adequate services for people who live with mental illness until people in positions of power — the CEOs and managers — say ‘I’m mentally ill. I’m living and I’m working with it.’…I bet you’d see a lot more acceptance and money going to the people who need it most: those homeless, addicted and living on the street.”
In the meantime, the YouthCare-Ryther model, layering services to provide more holistic, wraparound care, shows great promise. “In the past the mental health [providers] have been over there and the chemical dependency people on the other side,” says Fox. “We’re beginning to see much more of a merger of the two.”
Service providers have known for a long time that mental illness affects homeless youth and adults disproportionately. By raising awareness about the connection and the struggle, and by combining forces, they are taking a big step towards addressing it.