Think of the homeless mentally ill, and someone like Norma Jean Wilson may come to mind. There she is, wearing everything she owns: three pairs of pants, two sweaters, three coats, sneakers without soles and two wool caps wrapped in scarves.
Matted hair hangs to her earlobes. Hands jitter as if electrified. Eyes dart from side to side, fixed on demons nobody else can see. Her speech is fragmented, all phrases with no thread.
She panhandles outside restaurants, collecting coins for doughnuts and thrift-shop clothes. She sleeps by day and walks all night, moving constantly in a city full of risk.
This was her life last October, when professionals at a storefront mental health clinic in West Baltimore first laid eyes on her. Since then, team members at ACT -- Assertive Community Treatment -- have guided her to a breakthrough.
Ms. Wilson, 49, now sleeps in the same bed every night, sees a therapist and takes medication that brings focus to her thoughts. And she speaks with a new vocabulary.
"Last night we watched television and went to a jazz concert outside," she says. "Someday, I want to learn to swim."
Sitting in a boarding-house bedroom, she wears crisp denim shorts and a clean knit shirt. She flashes a warm smile that puts others at ease.
As cities across the country struggle with homelessness, perhaps no population has proved more difficult than that suffering from severe mental illnesses such as schizophrenia, manic-depressive disorder and major depression. Poverty is just the beginning. Even if offered housing, many are too confused to pay rent, shop for food or prepare a meal.
Many find the street a welcome subculture that accepts them with few questions asked. On a given night in Baltimore, about 2,400 people are homeless, according to studies. About a quarter suffer from severe mental illnesses but receive only erratic medical treatment.
For 3 1/2 years, the ACT team has intervened in the lives of 120 of the city's homeless mentally ill -- packaging housing, substance abuse counseling, shopping trips and even showers with psychiatric care. The effort seems to be paying off. In a study, the University of Maryland compared the progress of 77 ACT clients with that of 75 "controls" -- homeless people who tapped the city's loose network of community mental health centers, hospital psychiatric wards and drop-in centers.
After one year:
* Eighty-one percent of the ACT patients were no longer homeless, compared with 60 percent of those receiving conventional services.
* Nine percent of the ACT patients were living on the streets, 10 percent in hospitals and jails. In contrast, 20 percent of their counterparts were homeless and 19 percent were in hospitals and jails.
* ACT patients made fewer visits to emergency rooms, spent less time in psychiatric hospitals, displayed fewer psychiatric symptoms and voiced greater satisfaction with their lives. More than 90 percent say they were involved in continuing mental health programs, compared with 60 percent of those who navigated the system on their own.
"It's a one-stop shop," says Dr. Anthony Lehman, director of mental health research at the University of Maryland Medical Center, which runs the program. "There are services in the community, but they are very fragmented. You can go to a community mental health clinic and get medication and treatment, but you probably can't get housing and case management there."
The team includes psychiatrists, social workers, nurses and former mental patients serving as "consumer advocates." In 1991, it was established with a $3 million, three-year federal grant. Now it runs off a state grant and Medicaid reimbursements. Funding is obtained by Baltimore Mental Health Systems Inc., an umbrella organization that oversees programs serving the mentally ill.
The team treats 75 people, most referred by hospitals, soup kitchens, drop-in centers and other programs. They have spent an average of five years on the streets.
Nobody has been able to determine how long Ms. Wilson was homeless.
"As best we can determine," says her psychiatrist, Dr. Ann Hackman, "this lady has years that are lost."
This is Ms. Wilson's account:
In 10th grade, she dropped out of Southern High School to care for her two children, a boy and a girl. She moved into a Cherry Hill housing project, connecting briefly with other young women rearing families. But parenthood was overwhelming.
Occasionally, she would pay a baby sitter $100 and leave the house for a few days of drinking. Sometimes, she would pop amphetamines while drinking whiskey and beer.
"I couldn't make it by myself, so I gave the children to foster care," she says, adding that she saw them only a few times after that. She worked brief stints in a brush factory and a restaurant kitchen. For two years, she stripped on The Block.
For a while, she lived in cheap hotels, then she became homeless after repeated failures to hold a job.
She was becoming increasingly confused, tormented by voices only she could hear. "They'd say that I was going to die, and that everyone hated me," she says.
"On the streets, it was hard being there. You just have to be careful and move around a lot. Sometimes, men bother you. Some of them talk to you, asking you for cigarettes, some drink coffee with you and cuss you out and go on about their business.
"They make approaches about sex, talk nasty to you. Some people don't bother you and go on."
She'd make the rounds of soup kitchens. She'd sit in the sun. Mostly she would walk. At least once, she was arrested for vagrancy and sent to a state psychiatric hospital.
Through records, Dr. Hackman learned that Ms. Wilson was admitted to Spring Grove Hospital Center in 1976 and Springfield Hospital Center a year later. "We've got a decade and a half after that," the psychiatrist says, "and it's not at all clear what went on."
Last October, ACT received a call from My Sister's Place, a downtown drop-in center run by Catholic Charities. Please come and see Norma Wilson, someone pleaded.
"She was hallucinating but couldn't clearly tell us about any of that," Dr. Hackman says. "You'd watch her, and she'd look around the room and was obviously responding to something else."
Suffering from schizophrenia, she was unable to sustain a train of thought. "You'd ask a question and she'd lose it in mid-thought," Dr. Hackman says.
Dedra Layne, a social worker, persuaded her to visit ACT headquarters at West Baltimore and North Carey streets and to accept a "crisis bed" at a shelter. Ms. Wilson, however, left after two or three days, declaring that she was bored.
She then tried a boarding house on Orleans Street, but lasted just four days. On Halloween weekend, she created a disturbance when she became fearful the house was being visited by ghosts, Dr. Hackman says.
After a week in the psychiatric wing of Johns Hopkins Hospital, she stayed just three days in the boarding house.
"She said she wanted to stay on the street," says Ms. Layne. "We planned to see her daily and give her medications each day, and she maintained contact for about two weeks. Then, she disappeared again.
"So I began to track her," says Ms. Layne. Every few days, Ms. Layne visited My Sister's Place and a midtown restaurant where her patient was well-known. Weekly, she called every hospital in town.
"We're very persistent," says ACT clinical director Nancy Krauss. "We don't allow a patient to fire us. We go out and get them, entice them to come back."
After a month or so on the street, Ms. Wilson showed up again at My Sister's Place. Once notified, ACT placed her in My Sister's Place Lodge, a boarding house on West Saratoga Street also run by Catholic Charities.
Ms. Layne then made a disturbing discovery. Ms. Wilson's disability checks were being forged and cashed by a friend to whose Calvert Street apartment they were being mailed. Ms. Layne arranged to have the $446 monthly checks mailed to ACT, where her patient draws installments to cover expenses.
Three or four times a week, Ms. Wilson stops by the ACT office to discuss her progress. She takes an anti-psychotic drug and a sedative that has eased her nighttime agitation.
"I'd get into this real spasmic pacing. I'd walk all night long and keep other people awake."
Perhaps most remarkably, she has stayed at the "lodge" for five months straight.
Behind its ordinary brick facade, the warm home has a comfortable parlor with a piano and a kitchen where 12 residents gather for breakfast and dinner. Upstairs, the room she shares with another woman has two beds and a dresser laden with soaps, lotions and other toiletries.
Safe and content
Ms. Wilson says she feels safe and content, and isn't bothered LTC the occasional spats that put residents at odds. She enjoys watching television and playing cards and board games, and marvels at a resident who makes toy dogs out of yarn and coat hangers.
When she checked into the lodge in January, Ms. Wilson signed an agreement that entitles her to remain for two years. After that, her goal is to find an apartment. But the thought frightens her.
"Not knowing what she will do next," Dr. Hackman says, "she worries about what it will be like to stay by herself."
At this stage of life, Ms. Wilson prefers to think about the present.
"I'm not looking for a change," she says, sitting on her neatly made bed. "I'm just going to get old, I guess."