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In the library of North Annex, a public mental health clinic just off Wisconsin Avenue in Georgetown, five adult patients go about shelving books sent in from the patient library at St. Elizabeths hospital in Southeast. The patients are dressed in jeans and sweaters, and all but one are white. Clinic staffer Steve Overby proudly tells a colleague that book shelving—part of North Annex’s day treatment program—is a “team-building exercise.”

In a nearby room, a therapist slogs through a “group counseling” session attended by one 23-year-old man detailing his problems with women. A sign outside the room reads, “Confidentiality is of the highest importance,” but the door is wide open.

Over the past 15 years, prodded by mental health advocates, the District government has planted centers like North Annex all across the city to treat chronically mentally ill District residents. The idea was a progressive one: Instead of committing every mentally ill person to St. E’s for lifetime confinement, the city would set up small neighborhood centers to provide medical care and counseling to mentally ill people, who could then live in their own homes and lead normal, productive lives in their communities.

But if North Annex is treating the seriously mentally ill these days, it’s doing a good job of hiding them. A look inside North Annex last month found a quiet, orderly government building occupied by a few visitors who displayed almost none of the obvious signs of chronic mental illness. No one was talking to himself or claiming to be Jesus Christ. No one came with a shopping cart.

Few of North Annex’s patients actually seem to fit the profile of the city’s chronically mentally ill residents. The average client served by the city’s mental health commission is black, male, and suffering from schizophrenia. In fact, 76 percent of the more than 8,000 clients in the city’s public mental health system suffer from chronic mental illnesses—mostly schizophrenia, but also other psychotic and manic-depressive illnesses—and nearly 90 percent are African-American.

North Annex offers a small-scale look at the massive failure of the public mental health system to treat mental illness outside St. E’s—a problem that only seems to be getting worse. According to mental health commission budget documents, the number of outpatient visits to the centers plummeted more than 15 percent between fiscal 1995 and 1996. The lack of utilization is one of the reasons that mental health advocates have filed a motion in U.S. District Court to place the District’s mental health system in receivership. All last week, mental health advocates and consumers testified before Judge Aubrey Robinson that, after 23 years of litigation, the District has failed to create a network of community services that actually serves the mentally ill, particularly those who are homeless.

The receivership motion comes out of a lawsuit filed way back in 1974 on behalf of mentally ill District residents, a case known as Dixon v. Kelly. The ensuing court order set out an ambitious plan to radically alter the District’s mental health system by moving patients at St. E’s to less restrictive settings. Early mental health advocates envisioned replacing the Civil War-era mental hospital with a “continuum of community-based services,” where the mentally ill could live in their own apartments, work in productive jobs, and receive medical treatment close to home. The District spends $40 million annually on the community-based clinics and a handful of homeless shelters for the mentally ill.

Since the mid-1970s, St. E’s has released nearly 6,000 people from its confines, many with instructions to report to community treatment centers like North Annex. But a lot of the patients have washed up again at St. E’s in need of treatment. The hospital’s revolving-door problem stems in part from a crippling flaw in the community treatment rationale: The neighborhood treatment centers are set up like any other medical clinic, based on the assumption that their clients—whose disabilities are mental, not physical—will find their own way to the centers and seek treatment.

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Not surprisingly, many patients do neither, which accounts for the multitude of underused community treatment facilities across the city. And even those former St. E’s patients who do make it to one of the centers have a hard time keeping up with their treatment there.

“The system was based on the idea that people are able and willing and understand that they need to come in for services,” says Willa Morris, director of Rachel’s Women’s Center, a D.C. homeless shelter. She explains that the mentally ill—particularly those who are homeless—have a hard time cutting through the bureaucracy that schedules appointments at neighborhood clinics. Even though the centers aren’t swamped with chronically ill patients, it can take three weeks to navigate the centers’ three-tier intake process just to secure a first appointment, according to Michele May, program director for the Calvary Women’s Shelter. “People who need medication can’t wait that long. Plus, intake can take three to four hours, and the intake person is not the same person as the case manager or the doctor,” says May.

Many of the people who need the centers’ services the most are homeless people who suffer from paranoid schizophrenia and actively resist psychiatric treatment. “The homeless folks don’t necessarily come inside for services, and traditionally the mental health system has delivered services that way,” says Morris.

And when St. E’s outpatients drop off the map, no one goes out to look for them. Regina DuVall, a 20-year veteran of the District’s mental health system, has seen the holes in the District’s mental health safety net. “It’s not the point of the clinic to call you,” says DuVall, a Dixon class member and president of the D.C. Consumers’ League. “It’s just assumed that you’ll be back in the hospital because you’re not taking meds.”

District mental health authorities have known for some time that the community centers aren’t reaching their clients. A 1992 court order in the Dixon case, in fact, required the District to dispatch several outreach units—known as Mobile Community Outreach Treatment Teams (MCOTTs)—to shelters, parks, and other homeless refuges to try to coax the mentally ill into treatment. Although city officials promised mental health advocates that up to five MCOTT divisions would be plying District streets by the end of 1992, the outreach campaign is tough to spot. “Now they have one that is neither fully staffed nor fully functioning,” says Robert Moon, Dixon coordinator at the Bazelon Center for Mental Health Law.

And like most District government agencies, the centers operate on schedules that accommodate their employees, not their constituency. According to DuVall and other mental health advocates, community center doctors commonly work banker’s hours—like 10 to 3 on weekdays—a practice that rules out appointments for working patients like her. She’s also had 3-hour waits to get medication from the centers’ pharmacies, several of which are open only during business hours and close daily for lunch. “It’s less expensive to stand around and wait for it than to take a bus and come back,” says DuVall.

As will happen to any business with lousy customer service, the centers’ clientele has started to evaporate. Advocates say the 15-percent drop in outpatient visits from 1995 to 1996 is particularly disturbing, because St. E’s continues to pare its resident population. The centers can’t blame funding cuts for the drop-off, either. The budget for a center at the D.C. General Hospital complex actually went up by nearly a quarter while its patient load dropped 14 percent. And the city’s largest clinic, on Spring Road NW, suffered a minuscule 2-percent budget decrease, but nearly a third of its patients disappeared.

The numbers suggest that more and more mentally ill people are going without treatment, but the reality is that the mentally ill are taking their business elsewhere. Frustrated by the city’s inflexible mental health services, private homeless shelters and mental health contractors have developed their own psychiatric services.

Morris says Healthcare for the Homeless, a group that has outfitted RVs as mobile clinics, now treats women at Rachel’s homeless facility because the deskbound psychiatrists and caseworkers from the city’s centers never come out to the shelters. May explains that mentally ill people—especially if they are homeless—need a lot more than just a mental health worker, but most of the community centers don’t handle housing or help people apply for disability benefits. She says the social workers who help clients use the mental health clinics “end up having to do most of the work anyway. So if we have a psychiatrist on our staff, why refer anyone to the centers?”

While homeless shelters have gradually assumed responsibility for mental health services, the city’s human services budget hasn’t changed much to reflect the shift. As a result, the District spends nearly $40 million a year to staff and operate underused community mental health centers, where highly paid doctors sit around waiting for clients who never show. City social workers waste their days helping a few mildly ill people stack books, while hundreds of schizophrenic people build villages out of cardboard on city steam grates.

No one from the mental health commission, including newly appointed Commissioner Eileen Elias, would talk about the state of the centers, citing concerns about the pending receivership motion. But one of Elias’ stated performance goals is to funnel more money into community services and less into St. E’s. If she’s smart, Elias will buy Healthcare for the Homeless a few more Winnebagos and close the door on North Annex.CP