Categories
Homelessness Observations Reflection

Continuity of Care.

The first time I saw him he was walking around the shelter with another man. His hands were buried in the pockets of his hoodie and his gaze was fixed on the ground. He looked shorter than his actual height because he was slouching.

He and the man walked laps around the shelter while they talked. His expression was hard: Eyebrows furrowed, jaw tight, lips curled into a slight frown. He moved across the tiled floor like a sleek fish gliding through the water.

“Hi,” I said, introducing myself. “Do you mind if we talk for a few minutes?”

His companion kept walking as he coasted to a halt. His stony expression softened; his eyebrows raised and wrinkles appeared at the outer corners of his eyes as he smiled.

“Sure. Thank you.”

He and I walked laps around the shelter for the next few days. His father beat his mother, his brother, and him. At the age of 11 he found his mother’s body after she committed suicide. His father disappeared for days at a time. When he returned, his speech was slurred, clothes were dirty, and exhalations were thick with malt liquor. He stopped attending school. He ran away from home. He slept in alleys and underneath bridges. The police picked him up on a variety of charges: Theft. Drug possession. Criminal trespass.


The second time I saw him he lying on a mat in the shelter. The stiff blanket was not long enough to cover his entire body; his feet with their long toenails poked out.

He pulled the blanket off of his face and replied, “Heroin. Couple days ago.” Pulling up a sleeve, he showed me the collection of tiny bruises on his arm. He closed his eyes. Beads of sweat collected on the pale skin of his forehead.

“I’ll be done kicking dope tomorrow.” He pulled the blanket back over his head.


The third time I saw him he was sitting on the floor in the shelter, his arms hugging his knees.

“I don’t make many promises. I promised her that I won’t kill myself. I keep the promises I make, so I didn’t do it. I really wanted to.”

He accepted the invitation and got up. He and I walked laps around the shelter. He had yet to talk with her, though he planned to see her tomorrow. The last time he used heroin was over six months ago, but he was also in jail for four of those months.

“You didn’t use anything in jail?”

He shook his head.

After a pause, he said, “You know, I’ve seen you downtown. You were with a guy, so I didn’t want to bug you.”

“Is that where you’re staying these days?”

“Yeah.”

“Outside?”

“Yeah.”


The fourth time I saw him he was standing on the sidewalk outside of a methadone clinic. The hood of his sweatshirt was pulled over his head and baggy jeans covered his long legs. His hands were buried in the pockets of his sweatshirt. The other man made a joke; he chuckled and wrinkles appeared at the outer corners of his eyes as he smiled.

I crossed the street. He was with a guy and I didn’t want to bug him.


The fifth time I saw him he had already passed me. Without realizing that I was reviving an old habit, I wrapped the long white coat closed as I looked over my shoulder.

“Smith!” the officer barked. “Stay where you are. Turn around.”

He stopped, turned, and looked up. We saw each other.

“Go back to your cellblock, Smith.”

He moved across the concrete floor like a sleek fish gliding through the water. Before he passed me, he nodded in recognition. I nodded back.

We both kept walking. I sighed.

Categories
Homelessness Seattle Systems

Did You Nominate Me for Seattle Mag’s Community Service Award?

Hey, there’s a short blurb in Seattle Magazine about my work during the past two years:

Top Docs ’14: Community Service Award Winners

Scroll down to “The Bridge”. (If you want the source that “more than 60 percent of chronically homeless people in cities nationwide face lifelong mental health problems”, it’s here.)

Thank you to whoever nominated me! (Please tell me who you are.) It was an delightful surprise.

(In the meantime, I’m asking readers for help for post ideas on Facebook and Twitter. I welcome your suggestions.)

Categories
Homelessness Observations

All Four Seasons.

Green leaves are budding from the trees lining the city streets. The branches sway from the weight of small birds, their throats full of song. The chill in the morning air melts away as the Spring sun warms the ground, beckoning the flowers to push through the damp earth. Pedestrians carry their umbrellas and weave around the puddles on the sidewalk.

Some of them do not see the soiled sneakers poking out from under the bundle of blankets heaped in the shop doorway. Some people cast a sideways glance and say nothing. They have places to go.

People turn the calendar pages and begin to wear white again as Summer breezes into the city. The air is thick with moisture and the asphalt radiates the heat of the sun. When shop doors open and the cool conditioned air whooshes outside, people wearing strappy sandals, twill shorts, and thin tank tops sigh with relief. Fireworks light up the sky, people have picnics in the park, and the kids catch fireflies at night.

The bundles of blankets have moved underneath the bridges and along the banks of the river. The shop owners, taking advantage of the longer hours of the season, throw away the flattened cardboard boxes they find near their doorways. These are entryways, not platforms for beds.

The arc of the sun shortens and fog begins to drift into the city. The once verdant trees now don red, orange, and yellow leaves. The Autumn rain begins to fall. Kids pile into school buses and adults board the train, all daydreaming about their summer adventures.

The bundle of blankets appear downtown again. The blankets get wet from the frost in the woods. Rectangles of cardboard, piles of blankets, and rolling suitcases collect under the awnings of buildings.

Old man Winter hobbles into town. Freezing rain and snow fall from the pewter sky. People hurry to the store to stock up on toilet paper, bread, milk, and canned food. Their breath turns to white mist as they mutter about the cold and prepare for several feet of snow. Smoke floats out of chimneys, readers snuggle with books, and the kettles whistle when the water boils.

The bundles of blankets poke out of cardboard forts dressed with tarps or garbage bags. The snow is already collecting on the corrugated roofs, which sag from the wet weight.

“If you see someone in need during the storm,” the newscasters say, “if you see someone who is homeless, call this phone number.”

The homeless are there all the time. They are there all four seasons.

Categories
Education Homelessness Policy Reflection

Commercial Sexual Exploitation.

I recently attended a presentation given by one of the founders of The Organization for Prostitution Survivors (OPS).

If you or your organization want to hear a compelling, educational, and thoughtful talk about commercial sexual exploitation, I encourage you to contact OPS.

The talk did not necessarily alter the way I go about my work as a psychiatrist, but it did challenge my assumptions about prostitution, highlight the different perspectives men and women have about sex (to be clear, the talk was not at all “anti-male”), and encourage me to reconsider the influences of our culture on commercial sexual exploitation.

I’ve included my notes and reactions from the presentation below. Any errors and lack of clarity are entirely mine.


The speaker (a man) began with a discussion about the social construction of gender. What does it mean to “act like a man”? The stereotype is that a “man” excels at sports, fights well, doesn’t show emotions (particularly sadness, fear, etc.), is dominant, and is skilled at and knows a lot about (heterosexual) sex.

Boys learn these stereotypes throughout their youth. Boys are eventually introduced to pornography, which may actually serve a means of male bonding (passing around a copy of Playboy, sharing links to online pornography, etc.). Pornography doesn’t teach boys how about sexual relationships, but instead offers flat, two-dimensional representations of women solely in the context of sex. Masturbation leads to orgasm, which is a potent reward for viewing women as sexual objects (instead of actual people).

The speaker then asked the audience for adjectives attributed to “good girls” and “bad girls”. The assumptions about “bad girls” are often the same for prostituted women[1. The speaker used the phrase “prostituted woman” instead of “prostitute” for the same reason that I use “man with a diagnosis of schizophrenia” instead of “schizophrenic”. Let’s please remember that we are talking about actual people here.] (they have multiple sex partners; they drink alcohol and use drugs; etc.). The words we use to denigrate women are synonyms for prostituted women: whore, slut, etc.

As a consequence, prostituted women become a legitimate target group for male violence. We somehow come to believe that it is okay for men to hurt prostituted women. They are, after all, “bad girls”.

The speaker discussed Gary Ridgway (the “Green River Killer”), who sought out prostituted women and murdered them. Nearly half of the women he killed were under the age of 18. The speaker asked why the media consistently describes these women as “prostitutes” and omits that nearly half of them were, in fact, “children”? What if we described Gary Ridgway as the “most prolific killer of children” in American history?

The speaker then described how a former pimp would find and select women (girls). His strategy was essentially this: If he spoke to a woman and she responded with any direct eye contact (even if she was flattered), he would walk away and end the “grooming” process right there.

Why? Because he knew that those women who made no eye contact with him already had life experiences that would make the pimp’s job easier. “Someone else has already beaten her down so I don’t need to do as much to make her work.”

The speaker then noted that researchers often wonder about the mental health of prostituted women… but why hasn’t anyone examined the mental health of buyers and pimps (mostly men)? Prostituted women often develop PTSD, which is unsurprising given the chronic trauma they endure while working. What is wrong with us as a society that we haven’t shown the same interest in what is “wrong” with the johns?

A discussion followed about the words we use to describe men viewing women. In the US, we often say that men “ogle” or “leer at” women. Those words have a “hubba hubba hubba!” quality to them; men who want an interactive, romantic relationship don’t “ogle” or “leer at” women. When was the last time you heard of a man “beholding” a woman?

One of the most striking points the speaker made was when he asked, “To the men in the audience: What do you do to protect yourself from rape?”

Silence ensued. Some men in the audience were perplexed.

“To the women in the audience: What do you do to protect yourself from rape?”

Many women answered immediately: “Travel in pairs.” “Keep my drinks with me at all times when I’m out.” etc.

Both men and women in the audience were stunned at the disparity of responses.

The speaker then discussed the issue of consent: Consent for sex should be an “enthusiastic yes!”, not something that requires negotiation. In prostitution, the exchange of money for sex is coercion. Economic coercion is never true consent.

The speaker also commented that buyers aren’t paying to learn the reality of the prostituted woman. If the girl is 16 years old and the buying man asks her age, of course she is going to say that she is 18. If he asks her if she has a pimp, of course she will deny it.

The speaker then challenged the audience to speak up even when someone tells a sexist joke against women. Doing so helps to construct a world of equality where women aren’t reduced to sexual objects. He commented that a sexist joke is on a continuum that also includes a man forcing his wife to have with him (“why did I get married if I couldn’t have sex with her whenever I wanted?”), paying a prostituted woman for sex, rape, and murdering women.

The speaker shared that prostitution “is like domestic violence on crack”. The cycle of abuse applies to both. He reported that prostituted women leave and return to their pimps between seven and ten times before leaving for good. It is often difficult for the women to leave because they often identify with their pimps due to something like Stockholm syndrome, though “trauma-bonding” is probably more precise. Prostituted women also frequently develop drug and alcohol problems as a means of coping with the ongoing trauma associated with the work. (Imagine getting into the cars of buyers multiple times a night without knowing if you will get hurt; imagine a pimp beating you because you did not bring back sufficient earnings; etc.)

The speaker also discussed the “bad date list”, which has historically been a paper list that prostituted women have passed around with names and identifying information of buyers who don’t pay, hurt the women, etc. He said that they hope to develop a “bad date” app because of the ubiquity of smart phones.

The speaker closed by discussing different models of managing prostitution in societies. He said that he is strongly opposed to legalized prostitution. He cited some data where states and countries with legalized prostitution often results in more sex trafficking and prostitution. He gave the example of Germany: The demand for prostitution has gone up since it has become legal, so Eastern European women are often lured and trafficked into Germany to work as prostitutes.

He expressed hope in the “Swedish model“: Sweden has taken the approach that women working in prostitution are victims and, thus, the selling of sex is not considered a crime. However, buyers, pimps, and traffickers are prosecuted to the fullest extent of the law. Some data suggests that, as a consequence, there is less visible prostitution and fewer women working in prostitution.


Categories
Education Homelessness Lessons Medicine NYC Policy

Involuntary Commitment (V).

Recall that the first scenario described a homeless woman who did not seem inclined to move to shelter despite the forecast of a heavy snowstorm. How would you apply involuntary commitment criteria?

1. Does this person want to harm himself or someone else?

There was no evidence at that time to suggest that she was considering suicide or homicide. One might wonder about grave disability, as her behavior in that context was not consistent with most other homeless people at that time. (Because of the pending snowstorm, most of the homeless encampments were empty that morning.)

2. How imminent is this risk of harm to self or others?

Imminent. The snowstorm had already started and six inches were forecasted to cover the ground in the next few hours. If the snowstorm occurred as predicted and she did not move, she would be at significant risk of developing hypothermia, frostbite, or complications from both.

3. Are these behaviors due to a psychiatric condition?

Maybe.

She had mentioned one thing (“The government secrets are safe with me”) that might suggest a delusion, though we don’t really know what she meant when she said that. Her behavior suggests paranoia, though it is also understandable if people don’t want to talk to strangers.

Just because someone is homeless does not automatically mean that mental illness is present, though individuals who are chronically homeless are more likely to have a mental illness. Given what we knew about her, it seemed more likely than not that she has a psychiatric condition.

Related: Will hospitalization help treat the underlying psychiatric condition?

Maybe.

If it isn’t clear if she has a psychiatric condition, then it isn’t clear if hospitalization would help.

So what actually happened?


The outreach workers working with me wanted to send her to the hospital for evaluation and treatment. I wasn’t confident that she would actually be hospitalized. If I was working in an psychiatric emergency room, I probably would have released her. Her presentation did not seem to meet a minimum threshold for dangerousness, though she did not appear well.

The snow continued to fall. No one said anything. I excused myself to step away and consider the options.

I was worried about her. She had reported that she had been homeless for decades in New York; this wasn’t the first major snowstorm to hit the area. However, she was now older and just because she survived past snowstorms did not mean that she would survive this one. Furthermore, other individuals with comparable experience with homelessness had abandoned their campsites that morning—why hadn’t she?

In New York State, two physicians are required to detain a person against her will. If I began the process in the street, the emergency room psychiatrist could either complete the process or reject my proposal and release the individual.

With reluctance, I ultimately began the process for involuntary commitment. I was not convinced that she needed hospitalization, though I knew that the process would take several hours. Hopefully, the snow storm would blow through in that time.


She wasn’t pleased when the ambulance arrived (“I’m fine… I’m fine…”), though she did not resist the paramedics. I sat in the back of the ambulance with her. She was shivering. Neither one of us said anything; what could we talk about?

“So… what do you think of this weather we’re having?”

Upon arrival at the emergency room, I gave a brief report and the commitment paperwork to the psychiatrist on duty. The psychiatrist commented that he had never seen her before, which did not surprise me: Sometimes the most vulnerable and ill individuals never interact with the health care system.

“From what you’re telling me, I don’t think we’re going to detain her,” the emergency room psychiatrist said.

“I understand.”

A guard and a nurse asked her to empty out her pockets and remove her parka. She did not balk. Though I knew she was thin, I was taken aback with just how slender her frame was.


The snowstorm blew through. Close to eight inches collected on the ground. The rare pedestrian dashed across the empty streets through the blurry grey air.

I got a phone call as the storm was ending.

“We’re not going to hospitalize her; there’s not enough.”

“That’s fine. Thanks for letting me know.”


The next time I saw her she was standing on a corner, her hands in the pockets of that same parka. When I greeted her, she turned around and walked away quickly. She spurned my greetings for nearly three months.

I understood and could not blame her.

Only after three months did she finally agree to talk with me. One brisk morning, while she was still tucked under the plastic bags filled with paper, she finally told me her story. She probably demonstrated significant psychiatric symptoms in the past (and was probably diagnosed with schizophrenia), though she experienced less symptoms now. She still didn’t want housing because she believed that she didn’t deserve housing.

I left New York and she remained. I still think about her occasionally and wonder if she is still alive.