Despite the various. brief ministrations of regular visitors, a brilliant, talented, 48-year-old woman died homeless on the streets of New York. Her last personal abode, a 36-square-foot sidewalk grate, was at the base of the Helmsley Building in Midtown Manhattan. Strangers offered a modicum of conversation, transient care, and limited generosity. Sidewalk vendors guarded her and her belongings. Restaurant owners allowed her the use of their restrooms. Some regular visitors brought her food and warm clothing. She routinely beat back efforts to refer her to shelters or to treatment facilities. When pressed she would withdraw under signals of an abiding paranoia, and at times she could be seen conversing with hallucinated voices. The author of the article detailing the terrible sad life of Nakesha Williams chronicled her life with events signaling the onset of symptoms—paranoid delusions and hallucinations—that were routinely ignored. Ms. Williams spiraled down a clinically familiar path of schizophrenic decompensation. Never apparently acting overtly on her paranoid delusions, never becoming violent or threatening or even socially disruptive, she took, instead, a path of avoidance and, in effect, of hiding in plain sight.Letters poured into the New York Times responding to that initial editorial. Several of these letters expressed dismay at the public service system that was not more actively responsive, Some wondered why her regular visitors did not find some means to get Ms. Wiliams into treatment.Part of the problem lies with the nature of paranoid delusions. These tend to rest on two principles: one is the belief that malignant forces, often embodied by powerful suppressive and secretive agencies such as the FBI, are plotting against one. The second principle derives from a supremely unwarranted grandiosity which spawns a belief that one is too powerful, too important, too envied, perhaps too beautiful to be tolerated by the world at large..

"She had her admirers. Their hands-off manner was not threatening."

.Protection from such delusional enemies requires the pursuit of anonymity, the selective use of support sources (housing, food, clothing) that can be acquired without immersing oneself in extensive, self-revealing relationships. Work is not possible because it provides a locatable identity and, in a stable social milieu the delusional forces will inevitably find allies among peers.Ms. Williams entertained and impressed visitors stopping by for a chat and often a hand-out. But those conversations, mostly about books and authors she liked, only reinforced the grandiosity that lit the fire of her paranoia. She had her admirers. Their hands-off manner was not threatening.I know of a woman who lived in a similar destitute void. For years she evaded all treatment, surviving on the minimal help she accepted from longtime friends whom she would not permit to approach or truly help her. When her condition became physically desperate, she was forcibly taken to a psychiatric hospital. There she was given anti-psychotic medication and discharged. Her years of living in a grandiose but unreal delusional world suddenly shocked and horrified her. That world was filled with hallucinated works of art that she created mentally and effortlessly. She had even hallucinated a years-long passionate affair with a man who she had only actually met once. When the anti-psychotic medication took effect and all those symptoms vanished, the woman realized the enormous personal devastation her madness had wreaked. Her despair at the lost years and her lost life became the material of her therapy.Schizophrenia is a profoundly debilitating mental illness, now clearly identified as a disorder of brain organization and function. The cause is yet to be elucidated. Genetic markers do not yet point to a cause. Infections and physical and psychological trauma and street drugs may ultimately impinge on the brain and may occur during gestation, during formative years, perhaps even through prior effects on parental germ plasma.Anti-psychotic medications do correct - often eliminate - delusions and hallucinations. And there is an increasing body of evidence that very early intervention may prevent the full efflorescence of schizophrenia.But even with successful treatment, schizophrenia can leave a residue of deficit symptoms, which include diminished emotional range, decreased conversational capacity, decreased motivation, and loss of social drive. Even patients with deficit-free schizophrenia may experience re-entry into life on medication difficult. Having been unmoored from the trajectory of their "normal" lives, they often find themselves out of step with social peers and doubtful of their capacity to face challenges of resuming education, attaining and sustaining employment, acquiring a loving companion or spouse, and living with the stigma of schizophrenia.There are three and a half million schizophrenics in America (0.8% of all world's populations). Many, like Nakesha Williams, are living on streets everywhere. When will help be really on the way?

Photo by Edu Lauton