For one of his tenants and her incontinence, Tom Russell the landlord can install aerosol sprays inside her door and buy some time.
By chipping away at hoarded piles of bread and seed, he has managed to keep another woman and her obsession with birds safely sheltered.
And luckily the neighbors in this particular Kansas City apartment building can tolerate the young man who lies in the stairwell, slapping at the tile, listening to the resonating sound.
But there’s another man, a pliable Vietnam veteran, who can’t seem to turn away the opportunistic drug abusers and prostitutes who keep squatting in his room.
It’s moments like this when the “housing first” approach to treating people with severe mental illness and addictions meets its match.
In the past, the mental health world believed the more difficult patients needed to be treated first before they could be considered ready for housing with neighbors.
Now more caregivers believe they need the stability of housing first if treatment is going to have a chance. That means quickly matching people with illnesses to a scarce supply of supportive, affordable residences.
But the movement to house them is struggling.
Too often caseworkers are overburdened or not involved. The states’ hotlines, several housing specialists said, are mostly “useless.”
And sympathetic landlords like Russell “try to recruit whatever remnant of family or support agency” that might be left out there, “and try to find them the next place to live.”
But sometimes time may run out for one of these residents Russell talks about on a first-name basis. Sometimes he has to deliver the message, this time to his veteran: “I’ve got to evict you.”
Throughout the Kansas City area, agencies and advocates are determined to provide the kind of supported housing they think gives people with mental illness their best hope for treatment.
In many situations, it takes persistent caseworkers.
It takes carefully nurtured relationships where paranoia and distrust are constant foils.
It often requires on-site aides when new tenants, chronically homeless, may not know how to turn off a faucet, operate a stove or lock the door.
And perhaps most of all, said Shelley Johnson, a social services volunteer who, like Russell, lives in the Perry Place Apartments building, it requires awareness and compassion from everyone.
“If you live their story, you know their story,” she said. “By the grace of God it could be you or I.”
Gaining a foothold
James Glenn knows “housing first” isn’t easy.
As executive director of Kim Wilson Housing Inc. in Kansas City, Kan., he tries to supply support to landlords on both sides of the state line, as well as oversee the agency’s own portfolio of specialized housing.
But he sees the idea digging in. It’s gaining a foothold even as social services are starving for resources from the cash-strapped states.
The shift in thinking is winning because of “the economic argument,” he said.
Preventive care is always cheaper. Housing costs many times less than a night in a hospital emergency room or in jail.
By his agency’s accounting, a night in supported housing costs some $30, against $70 a night in jail or more than $1,000 in the ER.
And trying to treat mental health in jails or shelters, or having to track down clients on the streets, presents its own obvious problems.
“We’ve learned that housing is an intervention — as well as an outcome,” Glenn said.
The system has to be nimble. “Rapid rehousing” is the term. One client’s needs and behaviors might not fit the first shot, and housing specialists have to be able to place the resident in a new setting.
But there are not enough options right now, says Kansas City Municipal Judge Joe Locascio.
The latest numbers from the annual point-in-time count of people who are homeless shows what advocates for the mentally ill, like Locascio, are up against.
Of the 1,452 homeless people counted in Jackson County in January, half reported to be suffering chronic substance abuse, and some 40 percent reported severe mental illness, and many suffered both.
Locascio, as judge, for years has watched many of them cycle through his courtroom, charged with small crimes of trespassing, creating disturbances, shoplifting — sometimes because of psychotic breaks, sometimes just to get a meal in jail.
A new crisis center, opening July 1, will ease one of the major problems for people in psychotic distress — giving police a place to take them to stabilize other than jail or emergency rooms.
But it’s the next step that troubles Locascio now. “They need a place to go,” he said, “where a caseworker can find them and they can stay on their medications.”
“It’s Maslow’s hierarchy of needs,” he said. Everyone needs a place to sleep, to be safe and to find a “sense of belonging” before they can hope for better health and growth.
People hoping to help are meeting constantly, looking at creative options like tiny houses and converted storage containers, Locascio said. The state budget pending before Missouri Gov. Jay Nixon and the legislature includes $2.5 million for follow-up services and caseworkers for the crisis center, money that would also leverage more federal funds.
Struggling to help
Blaine Proctor likes to tell the story of a police officer who regularly visited with a woman encamped under a bridge.
He’d chat with her, said Proctor, the executive director of the specialized housing agency SAVE Inc., and at some point he’d always ask: Can I help you with a place to live?
Every time it was “No,” he said. No … no … no … no.
Then one day she said, “Yes.”
So many of the people advocates want to save don’t want the help or don’t know they need it.
The slim chances that services have to keep vulnerable people in safe housing depend on careful, persistent relationships, Proctor said.
Because there aren’t, and won’t be, enough professional caseworkers and counselors to bear the relationship burden, laypeople have to find the will to help.
Michelle McCray is another landlord who’s “jumping through hoops,” trying to keep her periodic crisis tenants off the streets.
She manages a midtown highrise that takes in mentally disadvantaged clients among its tenants.
“The last thing I want to see is one of them on the corner who hurt himself or someone else,” she said. “I want to know at least I tried.”
Often if someone is in enough of a crisis that they are in danger, police can take them to a hospital, but they’ll typically be back within three days, still in distress, she said.
The states have crisis hotlines, but the mental health professionals who respond on the phone or to the housing site take limited action as well.
At the Kansas City-based specialized housing agency Phoenix Family, they know the sometimes-bewildering quandary the hotline responders are in when a resident is in potential danger, but not imminent danger.
A person dependent on psychotropic medication has a right not to take it, said Nicole McGee, Phoenix’s human services manager. Simply fearing a crisis can’t bring aid. “Call us when something happens” will be the hotline’s response, she said.
Even when she said she feared for a resident who was depressed and saving used tissues in piles 6 feet high — and smoking — the crisis was not imminent enough.
Phoenix Family keeps on-site managers to be familiar with residents and nurture relationships, like the landlords who are willing to take chances on the community’s neediest members.
And those willing, said Jennifer Ham, to take on all these difficulties “is a short list of landlords.”
Ham, as executive director of a payee service, BFMA, under the regulation of the Social Security Administration, tries to help people with mental illness and addictions manage their disability checks and get their bills paid.
Her biggest struggle, likewise, is keeping her clients housed. Some come with caseworkers, and that’s the best shot. Some of her clients refuse housing. They walk out, preferring to take their chances to keep more of the money from their scant disability checks.
And that’s their choice too, Ham said. “We can’t be the morals police.”
‘What do you do?’
Meanwhile, people who evade the man or woman on the street with mental health issues should reframe their thinking, said Robbie Phillips, a program director for Truman Medical Center Behavioral Health.
“People see them as dangerous, but most of the time our people are the victims, not the perpetrators,” he said.
When Truman Behavioral Health is triaging the people it serves who need housing and treatment, it applies a vulnerability index.
That’s “vulnerability to death on the streets,” he said.
At Russell’s building, Johnson has watched in vain as some of the ill residents squandered the chance for a clean roof over their heads.
“They go back to what comforts them,” she said. Drugs and alcohol may seem more important than housing to them, she said, “and that’s not so hard to imagine when you have nothing.”
“What do you do,” Russell said, “when it gets to the point you no longer have the resources or the energy, when (a tenant’s behavior) is affecting the neighbors, affecting pest control and there’s hoarding?”
You can evict, “or you can work harder to keep her housed,” he said. “That’s where the long hours come in.”
Later, Russell stood outside the front door and waved to another tenant, a jovial man in a tweedy bowler and jacket who had stepped out for a walk.
A bank manages his bills for him, paying his share of his rent in a money order that he will often deliver wadded from his pocket, if he keeps track of it at all.
“We lose money on him,” Russell said.
At a distance now, the man in the hat stopped for a moment, alone on the sidewalk, a small figure facing away. Russell smiled sheepishly when it became apparent his tenant was urinating.
“If he wasn’t here,” he said, “he’d be on the street.”