The New York City Association of
Homeless and Street-Involved Youth Organizations’

State of the City’s
Homeless Youth Report 2003

MENTAL HEALTH 

Fred is a 21-year old homeless mentally ill immigrant.  Fred has symptoms of Post Traumatic Stress Disorder which are probably the result of extremely violent experiences he endured in his native war-torn country in Western Africa.  He often perceives himself to be in danger and can be quickly and easily aroused to defend himself, even when he is not immediately in harm’s way.  Fred’s ability to perceive danger may be greatly exaggerated and he frequently appears paranoid, however the most perplexing aspect of Fred’s story is that he often, in fact, is in danger.

Fred is living on the streets with virtually no supports.  He has been asked to leave every housing and drop-in program that he’s come in contact with because he often lashes out verbally and physically when he feels threatened.  He is a target for violence on the street due to his boyish looks and seeming inability to walk away from any dispute.  He finds it almost impossible to trust others, which is not surprising given his life experiences.

Fred has virtually no access to badly needed mental health services because of his illegal immigration status, his difficulty trusting others and the challenges in having such a potentially violent client in housing or counseling programs.  Although he has been willing to try psychotropic medication, he is unable to pay for it and not eligible for Medicaid.

Fred seems to be on a collision course with the criminal justice system.  Like many other homeless mentally ill youth, he will probably find the stable housing and long term psychiatric attention that he so badly needs in a jail cell.  Given appropriate supports and treatment, it is quite likely that Fred could stabilize enough to sort out what is and is not an immediate threat in his life and be able to function normally.  He is bright and eager for work.  Without access to a safe living environment, the chance to engage in long-term (not crisis oriented) psychotherapy and to psychotropic medications, it is unlikely that Fred will survive on the streets.

CURRENT STATE

            A disproportionate number of youth living on the streets in New York City are mentally ill.  That is, youth with mental health problems are likely to be found in greater numbers on the streets than they are in the general population.  This is not surprising for many reasons, among them that homeless and street-involved youth often come from backgrounds characterized by abuse and neglect (which is often a precursor to mood and psychotic disorders as well as personality disorders and difficulties); that homeless and street-involved youth tend to have higher levels of stress than housed youth and that youth who are mentally ill tend to “drift into” homeless due to their reduced ability to cope. 

            One of the largest studies done on the City’s homeless youth living in the shelter system revealed that 90% met the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for an emotional or behavioral disorder.  Three quarters of these youth met the criteria for a mood disorder, 41% had considered suicide and 25% had attempted suicide. (Feital, B. et. al., 1992).    At one drop-in youth program, approximately one third of all clients reported a history of contact with the mental health system (i.e., individual or family therapy, psychiatric hospitalizations, psychotropic medications or school-based interventions).  Another study of homeless adolescents revealed that 29% experienced psychotic symptoms. (Mundy, P. et al, 1990).  

            Sex work and homelessness, in addition to backgrounds characterized by severe emotional deprivation and physical and sexual abuse put street youth significantly at risk for post-traumatic stress disorder.  In a study of trauma and victimization among street-involved youth in New York City, 86% of  youth reported that they had experienced at least one traumatic event in their lifetimes, 53% reported having been physically assaulted by someone known to them, 44% had been sexually assaulted before the age of 18.  This study also found that the level of impairment experienced by these individuals as a result of past trauma was significant.  Over a third of these young people reported experiencing symptoms of PTSD. (Gwadz, 2002).

             Many street youth are eager to access or re-engage in mental health services.  In some instances, young people come to seek help from youth service providers when they are on the threshold of a serious mental health crisis.  If these youth are properly engaged, they stand a chance of having the impact of this crisis ameliorated by consistent support and access to badly needed care.

             For seriously and persistently mentally ill youth, trouble accepting their diagnosis is common.  This can be compounded when they explore services that are tailored primarily to older mentally clients.  For clients who need low-threshold services (i.e., drop-in or clubhouse model programs), the presence of older clients can be intimidating.  The clubhouses that exist are not equipped to handle the special needs of a younger population.  It can also be extremely frightening for a newly diagnosed young person to see the progression of a mental disorder in an older person.

             An overwhelming majority of homeless youth report some substance use, which can exacerbate psychiatric symptoms.  For these MICA (mentally ill chemical abusers) clients, it may be difficult for them to accept that their peers are better able to handle their drug use than they are.  Without access to the psychotropic medications that they need, some youth attempt to “self-medicate” their symptoms by using the drugs that are available to them.  Psycho-education is important to help MICA clients understand the impact of their drug use, however many youth are not at a point where they are willing  to give up their substance use “cold turkey” which makes them ineligible for abstinence-based MICA programs.  MICA programs with a harm-reduction orientation are much more likely to be attractive to youth, but even these can be intimidating to young clients if the staff is not familiar with the unique needs of adolescents.

CURRENT STATE AND EXISTING SERVICES

            Homeless youth can access mental health services in a variety of ways.  Drop-in center providers may offer counseling, therapy and psychiatric services.  Programs serving a broader section of the adolescent population may offer these services as well, although homeless youth may be less likely to seek them out because of the combined stigma of being homeless and having mental health issues.  There is only one emergency shelter in the city that has beds specifically designated for mentally ill youth.  Although this shelter also offers a psychiatric day treatment program, these services are short-term only and not available to clients who are over 21.  Other emergency shelters and transitional living programs in the City report that they have more difficulty accommodating clients with serious mental illness.  Line staff often feels inadequately trained and other residents may feel intimidated by psychotic symptoms or behavior.  Mentally ill clients can often find themselves in harm’s way when other clients feel frightened or threatened by their psychosis. 

            It is difficult to find safe and appropriate housing for all homeless youth, but a client’s psychiatric history can make the process even more onerous.  It is particularly difficult for MICA clients, clients with histories of multiple suicide attempts or clients with histories of violence or fire-setting.  Although in theory, New York City HRA housing providers accept mentally ill clients for supportive housing who are 18 and up, residences may be reluctant to take younger clients who they perceive as wilder, too street-involved or more disruptive than older clients.  The existing number of supportive housing beds falls far short of the estimated need.  In this environment, it is even less likely that housing providers will take a risk on a younger person when they can select an older, “more stable” client to fill the same bed. 

            Youth service organizations that do not have their own mental health services on-site (which are all but the largest) report difficulty in locating localized services and a lack of providers sensitive to the needs of homeless youth.  For these organizations, referrals to other youth providers can be limited by the specific intake requirements of other programs.  Quality psychiatric care, including medication management, is in alarmingly short supply with even the largest agencies only providing a few hours of psychiatric time per week to meet the needs of hundreds of clients.  These results in many young people having to manage their symptoms in emergency rooms after things have reached crisis proportions.

            Homeless youth often do not have medical benefits in place, despite their eligibility.  Clients without legal status in the country are not eligible for benefits at all.  Not having Medicaid or other benefits in place is an obstacle to obtaining on-going treatment, medication and housing.  Programs offering psychiatric services to clients without medical benefits face the additional problem of needing funding to cover prescription costs then the psychiatrist determines that psychotropic medication is indicated.  Once clients age out of the youth system, they have even fewer options for referral without benefits.

            Although there are a variety of services in place for homeless youth to address mental health issue, they are strikingly insufficient to meet the demand.  A greater understanding of the needs of this under-served population is needed within the mental health community.  Youth with mental health problems who are living on the streets are at risk of remaining there and becoming the older, hardened, more difficult to “street people” and “bag ladies” of the future.

            Appropriate housing is the most critical of all of the immediate needs of this vulnerable population.  Some estimate that 20% of the City’s homeless youth are in need of psychiatric care and supportive housing.  The New York State Office of Mental Health is equipped to provide these services to only 700 of these young adults.  Out of the 10,000 supportive housing beds for the mentally ill in New York City, only 22 are specifically for young adults.  This is grossly inadequate, given that by conservative estimates, services are needed for over 4,000 youth.  It is estimated that it costs $36,000 a year to shelter and individual, but it costs only $15,500 per year to provide supportive housing for them.  (Covenant House Mental Health Policy Brief, January 2003).

            For housing to meet the needs of these youth, it needs to be safe, have staff trained or prepared to address the issues that come up and to provide sufficient structure for clients who may not otherwise be able to create structure for themselves.  Without proper care and treatment, street youth are more likely to find themselves incarcerated, transferring the problem from the streets to the penal system.

            There is an overall shortage of psychiatric services available for homeless youth.  Psychiatric providers need to be sensitive to the needs of street-involved youth ad must be open to working within a harm-reduction framework.  Additionally, there is a lack of funding for psychotropic medications for clients who are without medical benefits.

RECOMMENDATIONS FOR MENTAL HEALTH SERVICES

·  Fund and provide more supportive housing beds targeted for young people.

·  Develop more MICA residences willing to work within a harm-reduction framework. 

·  Offer more drop-in/clubhouse/low threshold model services targeted especially to youth. 

·  Establish transitional living programs (TLP’s) specifically designed to meet the needs of homeless youth with psychiatric issues to provide on-going milieu support and treatment. 

·  Increase funding for psychiatric services. 

·  Strengthen relationships and understanding between agencies working with homeless youth and those providing residential mental health treatment. 

·  Assist clients in securing Medicaid so that they will have more treatment options.

REFERENCES

Feitel, B., Magetson, N., Chamas, J., Lipman, C. 1992.  Hospital and Community Psychiatry, February, Volume 43(2), p. 155 – 159.

Gwadz, M. 2002., Eighty-five Lives: Trauma and Victimization and Risk for HIV Among Street-Involved Youth.  Unpublished paper.

Mundy, P., Robertson, M.,  Robertson, J., Greenblatt, M., 1990.  Journal of the American Academy of Child and Adolescent Psychiatry, September, Volume 29(5), p. 724-731.

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