JOURNAL
ISSUE 1
1998/1999
Creating
Compassionate Community
Craig
Rennebohm
ABSTRACT
The Mental Health Chaplaincy began in 1987, as a response
to an increasingly visible number of homeless, mentally
ill individuals on the streets of downtown Seattle, Washington,
a city of almost 500,000 inhabitants. The chaplain walks
a daily route through the city center and nearby neighborhoods,
doing outreach and engagement with homeless, mentally ill
individuals who have lost contact with care or who have
no services. Outreach and engagement includes the four stages
of approach, companionship, partnership, and mutuality.
The aim is to share the journey from the street to stability
within the community assisting individuals to find and use
a variety of healing resources, and to foster the capacity
for welcome and hospitality in the community, and to establish
long-term, neighborhood scale patterns of care. The Chaplaincy
works with clusters of local congregations, assisting in
equipping churches to become centers of support with those
who have experienced major mental illness. A healthy neighborhood
includes those who are most vulnerable, stigmatized, and
liable to be on the margin. Neighbors will be willing to
share in the healing journey with a gift of themselves and
their experiences, wisdom, hope, and faithfulness. To address
the systemic causes of hopelessness, and maximize the healing
capacity of neighborhoods, the Chaplaincy has also been
involved in a wider process of community education and organization
around the needs and issues faced by those of us who struggle
with mental illness. The Chapliancy has been criticized
as utopian but takes heart from the example of Geel, Belgium,
with a 700 year history of neighborhood care for the mentally
ill.
For the last ten years the Mental Health Chaplaincy has worked
at creating neighborhoods able to care for those who experience
acute and chronic mental illness. A special concern has been
for those who are homeless, the person who is most vulnerable
and isolated. The Chaplaincy reaches out to build community
with individuals who are on the furthest margins of society.
They are people who often are estranged from family and outcast
from their own communities and culture, persons who are living
outside the system of social services
The 43-year-old
man was sitting in the park. Rain was pouring down. He was
soaking wet, having spent the night without shelter. He
said nothing when greeted, simply staring at the ground,
immobile. It took half an hour to establish contact, to
connect with this deeply depressed individual. We simply
sat in silence. My brief overtures elicited no conversation,
only the barest of nods after a while. And then finally,
slowly he agreed to walk with me to a nearby drop-in center.
A few blocks took more than an hour. Over a cup of coffee
he shared a little of his story. He had been in the Navy,
then administered a large office. He reported that he became
"sad," started drinking and lost his job. He went
on public assistance, received alcohol treatment, and stopped
drinking. The sadness returned. He simply laid in his bed,
stopped eating, and didn’t collect his mail. He missed
his
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appointments with the public assistance office. His
support was terminated. He was evicted and began months
of wandering the streets, sleeping in doorways. At the center
he was welcomed and introduced to a companion who helped
advocate with him for shelter, appropriate care, housing,
and a place again in the community.
This paper begins
with a statement and analysis of the problem of estrangement
and hopelessness among persons who experience major mental
illness. A vision of a humane and inclusive community is offered.
The fabric of support created to implement this vision is
described as a weaving together of outreach and engagement
services with an effort to establish long-term, neighborhood
scale patterns of care. The paper concludes with a brief retelling
of the 700 year history of Geel, and the development there
of a community deeply supportive of folk who face the long
journey with mental illness.
STATEMENT AND
ANALYSIS OF THE PROBLEM
In 1963 Congress passed the Community Mental Health Centers
Act. This marked a major shift in the way individuals with
mental illness were treated in the United States. Large state
hospitals were to be replaced by a network of community based
mental health centers.
Prior to 1963,
the predominant mode of care for individuals with acute and
chronic mental illness was institutionalization in a state
mental hospital. In Washington state, in 1963, there were
more than 6,000 individuals in three state hospitals, each
located in rural areas far from major centers of population.
The average length of stay was 25 years. Individuals with
serious mental illness spent most of their adult lives out
of sight and away from family and community. There would now
be 11,000 patients in the state hospital system in Washington
had the state continued to institutionalize seriously mentally
ill individuals in this same manner. There are however, 1600
individuals in the state hospitals, with an average length
of stay of six months. The vast majority of people who experience
acute and chronic mental illness are in the community.
Across the country
less than one-fourth of the expected community mental health
centers were built and placed into service. The network of
community-based care envisioned in the 1963 Community Mental
Health Centers Act has never been adequately implemented.
The King County mental health regional service network has
a capacity to serve approximately 8,000 clients in long term
care. There is an acknowledged requirement for more than 1,300
beds in various kinds of residences to meet the housing needs
of chronically mentally ill individuals, eligible for long
term care services from the county. The Downtown Emergency
Service Center alone reported an unduplicated yearly total
of more than 1,000 homeless, mentally ill individuals seen
in its facility.
Homelessness among
persons with mental illness is a function of both the lack
of adequate care and housing, and of the nature of brain illnesses.
Brain disorders affect the very organ with which we process
and organize our lives, severely altering or impairing the
capacity to feel, think, act and relate. Affective disorders
may plunge an individual into prolonged periods of hopelessness
and despair, or produce extended states of mania. Thought
disorders may include confusion and disorientation to time
and place, hallucinations, or delusions. Changes in brain
chemistry of anomalies in brain structure result in extraordinary
experiences and behavior which can be profoundly disturbing
to the individual, family and community.
The woman
lived on the streets. She felt deeply unworthy and guilty.
Her suffering was a punishment for which there was no possible
forgiveness or healing. Only in a state of utter exhaustion
and near physical collapse was she able to accept help.
The young
man was sleepless for days. He marched constantly around
the block, occasionally shouting to residents to get back
indoors. His duty was to protect the neighborhood from invasion.
His mission was authorized by no less than the Presiden,
and God. He felt himself invincible, with special powers
to fight off evil.
The man heard
voices. They directed his steps, told him what he could
eat, where he should sleep, what he must look for each day
to collect for his future. The voices told him whom he could
trust and whether he should talk.
The illness experience
may have led individuals out of connection and care and into
the street. The
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community and the world of service and resources
may be effectively lost to the mind once a person becomes
homeless. Even when an individual maintains some degree of
touch with reality, the programs have decepting registration
and admission requirements. Transitional and long-term care
services have a variety of interview and application steps
to be negotiated. The move from the street to stability for
a mentally ill person will necessitate working with a minimum
of four agencies and seven or more agency staff, if the person
continues to meet criteria for services each step of the way.
Management of
the public mental health system has been contracted to a private
insurance company. Admission to long-term care services and
residential resources have been effectively restricted to
individuals entitled to Medicaid - a federally-funded health
insurance. Geographic focus and responsibilities were eliminated,
making ties between mental health centers and neighborhoods
more tenuous than ever before.
The healing journey
can be inherently difficult to begin with, fraught with barriers
along the way, and frustrated by a lack of appropriate resources.
Downtown Seattle has the most resources available in the region
for homeless, mentally ill individuals. Even here shelters,
drop-in centers, health services and meal programs are found
only on the north and south periphery of the business, hotel,
financial and government core. Survival services and mental
health resources appropriate to the homeless and the most
fragile of mentally ill persons are significantly sparse in
the residential neighborhoods immediately around the downtown
core, and are almost non-existent in suburban and rural communities.
A group of church-based
programs working on the issues of homelessness in the Seattle
area concluded, after a three year consultation and cooperative
effort, that these patterns were not accidental. Homelessness
reflects the way communities are organized with respect to
who is welcome, the kind of services which are provided, and
what housing is available. The ideal community was comprised
of single family homes with public amenities such as libraries,
parks and schools, and shopping areas confined to the provision
of residential needs. Closer to the city center and business
zones, communities included multifamily housing and social
services perceived to be benign in their impact; for example,
programs providing care to the elderly. Special needs housing
and services for the least popular of populations were generally
relegated to poorer, transitional areas cut off from the mainstream
of community life.
This is especially
true for the most seriously mentally ill individuals in our
midst. Few, if any, neighborhoods have intentionally organized
their community to provide an adequate and appropriate continuum
of services for those most fragile and vulnerable in their
mental illness. Outreach workers, shelter providers, drop-in
centers, housing programs and mental health services seeking
to provide care for the most seriously ill and hard to reach
individuals with mental illness must work exceptionally hard
to secure entree, base and support, neighborhood by neighborhood.
To organize communities with a priority on hospitality and
support for those with brain illnesses is to introduce a fundamental
change in focus, not only in the treatment and care of neurobiological
disorders, but in the way we conceive and order common life.
A VISION OF CARING AND COMPASSIONATE COMMUNITY
The church-based homelessness working group developed a vision
of neighborhood to serve as a guide for the work of the constituent
congregations and programs. The key notion was that a healthy
neighborhood recognized and included those who are most vulnerable,
stigmatized, and liable to be on the margin or edge. The organization
of a healthy neighborhood makes intentional and proactive
provision for the stranger, the frail, the wounded, and the
wandering. Just as hospitality was a premium in the waterless
desert, so compassion is a primary virtue in the complexity
of contemporary urban life. The more highly organized and
demanding our social and economic life, the more intentional
and active we must be in providing welcome for and community
with those who are isolated, left out, and left behind.
At the heart of
the vision of compassionate community is refuge and sanctuary.
Each neighborhood is called to have a place where one can
rest and find aid 24 hours a day. An inn or two where the
runaway child, the distraught and abused mother, the confused
and suffering soul may be encouraged to come and begin healing.
Such a refuge should have ready access to acute care, and
be able to refer people to neighborhood emergency shelter
and other survival resources. Out in the community, and at
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the door, should be folk who have the calling and skill to
be present and listen, to build trust, discern needs, and
bear the pain and struggle with another.
As quickly as
possible people should have the benefit of participation in
the life of a healing community, as a guest or novice in the
process of moving toward a permanent, stable and meaningful
residency. The neighborhood should be prepared to minister
in the period of recovery and convalescence, as an individual
and family repairs, as treatment proceeds, as new awareness
and understanding is developed, and new skills and life practices
are learned. These transitional services may be linked to
more central, area wide or regional levels of resource, but
they will be characterized at the community level of the steadfast
involvement of neighbors willing to share in the healing journey
with the gift of themselves and their own experiences, wisdom,
hope, and faithfulness.
Provision should
be made for appropriate housing and for place in the economic
and social circle of the neighborhood for those who live with
a long term, chronic or degenerative impairment. Homelessness
ends not simply with a roof over one’s head, but with
a place where one is known, where there is supportive intimacy
with a small group of others, where one can always return;
a place where those who live nearby know and care about his
or her well being, a setting where one gives, as well as receives.
A middle
aged man suffers from a rare neurobiological disorder which
results in symptoms of both major depression and schizophrenia.
He was homeless for a period of two years in an uptown neighborhood.
His church was the one constant point of contact. Staff
and parishioners were puzzled and concerned about the man’s
behavior, his sitting long hours in the sanctuary and late
night wanderings in the church yard. In consultations with
the Chaplaincy, a plan of care was developed. One of the
pastoral staff was assigned as the primary contact with
the individual to build trust and provide consistent communication.
A lay person from the church served as an informal companion
by being available simply to listen and be present. The
Chaplain served as a third member of the healing team, assisting
with referrals to a mental health worker, shelter, the public
assistance office, and eventually transitional and long-term
residence. Even with medication, and a permanent residence,
the individual continued to experience occasional episodes
of illness when he left the apartment for the street. The
healing team has been able to act swiftly to assist in these
crises, and is now at a point, where, with the help of the
doctor and caseworker, early signs of illness onset are
recognized and treated, greatly enhancing this person’s
stability. A key factor in this five year process has been
the inclusion of the individual in the life of the congregation.
While unable to hold employment, the man volunteers regularly
in a variety of ministries and is recognized as an active
member of the parish.
COMPANIONSHIP IS AT THE HEART OF WORK
The Chaplaincy’s work of weaving a supportive fabric
of care, neighborhood by neighborhood, began with two efforts.
The chaplain developed and modeled a neighborhood service
of outreach and engagement with homeless, mentally ill individuals.
At the same time the Chaplaincy began training laity from
local congregations in these neighborhoods to serve as companions
of mentally ill individuals either in their church or in a
community setting.
Outreach and engagement
is a process which includes four stages: approach, companionship,
partnership, and mutuality. During the approach phase the
outreach worker begins by observing from a distance, noting
how a person responds to others, how able they are to tolerate
interactions and conversation, and what needs the individual
might have. The approach phase continues with brief attempts
to develop a connection, to say hello, to come gently alongside
the person. As the person is able and willing, the outreach
worker introduces himself or herself, as a neighbor, as one
who has interest and concern for another and their welfare.
As a relationship
is acknowledged, the approach phase of outreach and engagement
transitions into companionship, and the individual accepts
the presence of another. In companionship, the interest is
in sharing the journey, listening, and hearing a person’s
story. The notion of companionship roots in the Latin "cum
panis," "with bread." Companionship grows through
shared experiences of nourishment and nurturing, walking together,
sitting quietly in conversation, having a meal together. It
is not the giving or sharing of things that is important.
Getting a cup of coffee, finding a pair of shoes, walking
25.
together to the shelter, accompanying someone to an appointment
are occasions for being present and building a personal relationship.
In companionship there is a deep acceptance of the other as
they are. Companionship embraces the whole person, the illness,
homelessness, ragged clothes, as well as the uniqueness, beauty,
tenderness, history, gifts, and potential of this individual.
In companionship,
trust grows to a point where plans can be made and others
introduced to help with specific needs. The relationship experience
nurtured in companionship becomes the ground for admitting
others to the circle of care, as partners. In the phase of
partnership, the healing team companion serves as a continuing,
crucial resource, but is someone who does not play an instrumental
role in a person’s life. The companion is there to encourage
and reflect on and help the process of the emerging partnerships.
As a healing team
comes into place with a person who has been homeless and mentally
ill, as the partnership grows with others, the outreach and
engagement effort moves into a final phase of mutuality. Companionship
is deepened into a relationship of increasing equality and
reciprocity. Both partners share in an increasing wholeness,
neighbors sharing together a common community and human journey.
Fear, confusion, stigma, judgments, estrangement, and distance
are transformed in the direction of empathy and compassion.
The chaplain carries
out a regular, daily round of outreach and engagement services,
working with 40 to 50 people a year, and a dozen to 15 individuals
at any given time. What are the community analogues of the
outreach and engagement process? How can congregations and
their members participate effectively and appropriately in
assisting homeless, mentally ill individuals from the street
to stability? Where and how can laity play a role in approaching
and companioning persons experiencing mental illness, support
the formation of caring partnerships, and truly welcome the
estranged neighbor fully into the life of the community?
A first step has
been to design and implement a Companionship Training Curriculum
in both a six month and one day formats. The one-day training
is done ecumenically, to equip local church members for a
door-keeping ministry. The doorkeepers are available on Sundays
at their church with a special care for those who come in
need or seek help and assistance. The training includes an
introduction to homelessness, communicating with someone who
is experiencing symptoms of mental illness, listening skills,
hospitality, crisis intervention, and referral resources.
Fourteen churches in the four neighborhoods have participated
in the training and have Sunday doorkeeper companions. Trainings
are offered three times a year. Each church organizes its
own team of doorkeepers, which meet regularly for mutual support
and on-going education. Persons who themselves have experienced
mental illness or homelessness are encouraged to be a part
of the door-keeping ministry. The Chaplaincy provides an on-call
resource person to consult with questions or difficult situations.
This Sunday program
was developed because most other resources are closed on Sundays.
Folk from the street and people in need come to the one refuge
they know is open, the church. In the absence of an intentional
ministry of welcome and support, churches found themselves
overwhelmed and ineffective in responding to the individual
literally on their doorstep. Congregations expressed uneasiness,
fear, insecurity, and ignorance about how to act with marginal
folks in their midst.
Each church decides
the extent of material aid it will provide to individuals
on a case-by-case basis. Basic hospitality is offered-refreshment,
rest, and simple hygiene resources. A common set of referral
resources has been developed. The Sunday companions are prepared
to help secure food, shelter and medical care for the day.
The churches have identified three drop-in centers downtown
as inns where a person can be assured of respite and a place
for the night. Sunday companions in the door-keeping ministry
are practiced in introducing individuals to these resources.
The extended training
is designed to equip laity to serve as community companions
working with folks over the long haul either from a base in
their own church or a base in a community agency or program.
The final segment of the training introduces a process of
discernment, in which individuals explore and test their calling
to develop or participate in a particular ministry setting.
Plymouth
Church in downtown Seattle has developed some 600 units
of single room occupancy and low income housing in and around
the downtown core. The aim of the mission is to preserve
deteriorating housing from demolition or upscale development
for those most in need. The most marginal tenants became
increasingly unmanageable. Several of the early buildings
offered the least expensive rents and housing. One was closed.
A second remained open with the involvement of the Chaplaincy
and a group of Plymouth Community Companions. An agreement
was reached to set aside seven of the
26.
32 rooms in the building
for homeless, mentally ill individuals. A small community
room was carved out in the building, which had no public
gathering place. An associate chaplain coordinated the admission
of homeless, mentally ill individuals to the building with
the on-site manager, and was present several days each week
to visit each of the mentally ill residents and facilitate
community building and informal after dinner discussion
about resident issues, tenant needs, and life in the building
and neighborhood. Companions assisted with a variety of
outings, retreats and connections with neighborhood activities
and events, and encouraged individual residents in their
healing partnerships with caregivers.
The formula
of community and self-support facilitated by the chaplaincy
and the community companions became the model for a more
extensive effort at the Gatewood, a 100 unit building dedicated
exclusively to housing homeless persons. Community companions
are actively engaged there, basing their efforts on a weekly
Wednesday afternoon gathering of residents. Companions are
present, but also share their experience in such areas as
cooking, art, math and science, and literacy training as
people have interest. Companions have accompanied residents
to a variety of appointments, visited during hospitalizations,
tutored, assisted with moves into permanent housing, and
shared in outings. The Wednesday gathering has become a
time of reconciliation and renewal by helping residents
become acquainted with one another and opening up possibilities
and encouragement for next steps.
Community
Companions at Pilgrim Church have developed an ecumenical
resource center, open during the week to help people negotiate
the various agencies and programs needed to make the transition
to stability. Gathering volunteers from other churches,
the group instituted a caring neighbor’s program developing
vouchers redeemable at local businesses and social services
to meet a wide variety of basic needs identified by homeless
folks. Panhandling and community antagonism toward homeless
individuals was reduced as cooperation among various stakeholders
in the community increased in addressing the challenge of
homelessness.
A vision of compassionate
community has informed the development of the companionship
program in local churches. The Chaplaincy has provided training
and consultation, and occasionally initiated a specific service
model in partnership with a local church, cluster of congregations
or a community agency. The aim has been to act primarily as
a catalyst, relying on existing institutions and appropriate
structures in the community to help weave and maintain the
fabric of long term. Ten years have been used doing education,
laying groundwork, providing models and slowly nurturing grass
roots elements of outreach, survival resources, transitional
services and long term care.
FROM COMPANIONSHIP TO COMMUNITY ORGANIZATIONS
A guiding principle in the Chaplaincy’s work has
been that the organization of service and support be defined
from the bottom up and from the edge in. We begin with those
who are on the margin, and with those who have little or nothing.
A small self-supporting group, including folks who themselves
have been at the edge, is at the heart of each effort. Companionship
is both the basic mode of service and the way of organization.
The Chaplaincy, the Sunday doorkeepers and the community companions
are collegial gatherings. A conveyor helps facilitate the
meeting. Organizational gatherings most often occur over a
simple meal. The occasion begins with prayer or some other
meditative act. The group proceeds to reflect on scripture,
some gift of art, traditional wisdom, or current commentary.
There is good time for sharing, both about challenges, needs
and concerns, but also about the personal and communal journey
out of which we live and serve. The agenda grows from this
process of centering, reflecting and sharing, and concludes
with a period of discernment. Proposed actions are explored
and tested. Each person in the group is considered to have
an important voice. Decisions are taken by consensus. Those
who have difficulty understanding or accepting a step or direction
are honored as cautioning us to consider more carefully and
deeply our plans and procedures. Each project is responsible
for its own life and direction.
As companionship
efforts have grown, and more churches and laity have become
involved, new levels and forms of organizing in the community
have evolved. An ecumenical working group has been
27.
formed
to encourage collaboration among the Downtown and First Hill
Churches in the door-keeping ministry. The group is planning
to expand the Sunday effort to the rest of the week. A single,
common resource center was initially proposed, to which persons
coming to any of the churches would be referred. The plan
now is to deepen the capacity of each church to serve as an
entry station to care, to refer well and effectively to existing
resources, and to focus our creative efforts on filling gaps
in care.
Need for emergency
shelter and small scale transitional residences supportive
of healing and convalescence have surfaced repeatedly. A member
of doorkeeper teams has proposed a simple plan in which two
or three retired or single folks would pool their rents for
a home or apartment large enough to take in a guest or two.
This informal, intentional community would welcome the person
coming out of the hospital, or provide a first step off the
street. A second concern is how to build community and be
supportive of folks who continue to come by the churches.
The plan is to collaborate in offering a variety of occasions
for connection, from prayer and healing services, to simple
meals, to vocational opportunities.
The religious
community can provide a range of service of a Samaritan, innkeeping
and supportive nature. Much of the care and resources needed
by homeless and chronically mentally ill individuals, however,
must be provided by the wider community and the public sector.
We have been successful in having public health, human services
and special needs populations, including homeless and chronically
mentally ill individuals, considered in the scope of work
for neighborhood planning.
The hope is to
have the neighborhood plans and citywide growth management
documents address several key concerns. How will mental health
information, outreach and triage services be made available
at the neighborhood level? What public policy, procedures
and funding decisions are necessary to insure a network of
neighborhood scale survival, transitional and long term care
services for the most difficult to serve chronically mentally
ill individuals in our communities? In short, how do we organize
neighborhood, city and regional life in such a way that homelessness
ceases to exist for those among us with major mental illness?
We are building
a small group of neighborhood advocates who are participating
in the planning process. Ideas and suggestions are being brought
back to and received from the groups working on the front
lines and in the community. The experience and wisdom of those
who have been on the margins and without care is being solicited
and shared in the planning hearing and meetings.
GEEL, AN INSPIRATION
The effort to create compassionate community, able to welcome
and support chronically mentally ill individuals, is a task
of decades, even centuries. The Chaplaincy efforts have been
criticized as Utopian, impossible of achievement. We take
heart from the example of the community of Geel, Belgium.
At the center of the city is a psychiatric hospital. On the
grounds of the hospital are small centers for vocational training
in a number of economic areas traditionally reserved to those
who experience major mental illness. The city is organized
into five sectors fanning our from the city center. Each sector
has a mental health house open from early morning to midnight.
A healing team of psychiatrist, general practitioner, nurse,
social worker and psychologist works from each house. Each
team serves some 150 chronically mentally ill individuals
living with more than 700 families in every neighborhood of
the city. Each week the team nurse visits every home and patient.
The team spends time each day with their patients in a variety
of community activities - work, meals, sports, education,
recreation, and service. Each day hospital and community staff
meet to plan admissions and discharges. All hospital staff
spend at least half a day each week with a community team
and patients. Each community team member spends a half-day
a week at the hospital.
The tradition
of community care that is so richly developed in Geel emerged
over a seven hundred-year history. Over the years stigma has
been worn away. Understanding and patience have taken its
place. Ways have been found to welcome and include. Healing
is the calling of the whole community. In Geel, it is a privilege
to be a host family, a privilege to provide a home for someone
who is mentally ill.
Implementing the
spirit of Geel in the American context and in a diverse, multicultural
region is an enormous challenge. We have started, however,
as the people of Geel did in the 13th century. When they found
mentally ill folks on the steps of their parish church, seeking
aid, they took them in and offered such care as they could
at the most intimate levels of their life, in their church,
homes and neighborhoods.
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