Category: Homelessness

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Homelessness Seattle

Three Years.

My stomach lurched when I saw him.

He was leaning against a brick building, his fingertips gripping the walls as if they alone were holding him upright. His head swiveled back and forth in animated conversation.

He was standing alone.

He looked exactly the same as he did before I left Seattle for New York: Matted hair, unwashed skin, lopsided smile.

During my last year of residency, I spent one day a week working at a shelter. He unexpectedly appeared there one afternoon. Staff told me that he was an occasional visitor for the past fifteen years. When winter descended upon the city, they saw him more often. He disappeared during the dryer months.

Wary of psychiatrists—he had spoken to several in his lifetime—he kept our first meeting short.

“Would you be willing to come back next week so we can talk again?”

He shrugged.

To my surprise, he appeared the next week. And the week after. And the week after that.

He told me about his immigrant parents. He told me that he was an avid reader. He often had a copy of the local paper or a library book tucked under his arm when he came to the shelter. His vision was poor, so I’d often see his face inches from the pages. He squinted. He told me about the wooded grove he slept in, though would never tell me its exact location. He showed me the toiletries he kept in his duffel bag, including the razors he used to shave his face without any water or cream.

He never told me what happened that made him homeless. He never told me who he spoke to when he was alone.

Several months before my departure, I told him that I was moving to New York City. The lopsided smile blossomed on his face.

“I used to live there,” he said. The smile withered and his expression darkened. “Be careful. There are a lot of people there. It’s not a safe place. Especially the subway platforms. Make sure you always hold onto the columns in the subway stations.”

To demonstrate, he stood up and dug his fingertips into the walls of the office as if they alone were holding him upright.

Three years have passed and I have returned to Seattle. Three years have passed and he remains homeless with limited to no options for supportive housing. Three years have passed and the only things he can hold onto are the walls along the city streets.

Categories
Education Homelessness NYC

How Long Do People Stay Here?

Let’s visit a homeless shelter in New York City.

There’s no sign on the building. On the sidewalk outside of the unmarked entrance are several men. Three of them are chatting with each other. Two others are leaning against the wall, taking drags from their cigarettes. After you pass, one of them coughs up a wad of phlegm and spits it out. A man sitting on the sidewalk asks, “Spare some change?” He shakes a tattered coffee cup at you. The few coins inside jangle.

You try to pull the door open. It’s locked. Through the glass you see a few people looking out at you. They’re not smiling. Finding the doorbell, you press the white button. A few seconds pass. A harsh, steady buzz suddenly fills the air, informing you that you may now enter.

“Sign in!” a man barks at you. Behind the splintered desk is a man in a security uniform. He’s pointing at a log book, the page nearly filled with names in blue ink.

As you write in your information, he asks, “Who are you? Where you from?”

“Empty your pockets.”

“Open your bag.”

Satisfied with your answers and confident that you don’t have weapons, drugs, or alcohol, he steps out from behind the desk with a metal detector wand. After he waves it over your body, he says, “Go. You’re fine.”

Before you see the thick, plastic chairs in the main room, you smell the odor of fetid sweat. Seated in the chairs are men wearing unwashed jeans, oversized shirts, baggy jackets, and generic baseball caps. Some of them are reading newspapers and books. A few older women are sleeping upright, their chins nearly resting on their chests. One of them is wearing sandals; her toenails are discolored and misshapen from fungus. Her ankles look like eggplants. A young man seated in a wheelchair tries to drink his coffee, but his tremulous hand cannot keep the cup steady. Next to him is a man wearing a porkpie hat, red lipstick, two winter coats, board shorts over torn tuxedo pants, and yellow sandals. Three women are shouting at each other; one of them reaches for the neck of another and screams, “I’M GONNA KILL YOU, YOU—”

“How long do people stay here?” you ask, realizing that the room is filled with people. You can’t imagine living like this; you’d get out of here as soon as you could.

They feel the exact same way.

But you ask an excellent question. What is the average length of stay in a homeless shelter?

Some caveats: Data on homelessness is almost always incomplete and inaccurate:

  1. Researchers can only collect data that is available. People who stay in homeless shelters are available. People who live in cars, abandoned lots, and in transit stations—away from researchers—are generally unavailable.
  2. Researchers often must rely on the information homeless individuals share (“self report”). For a variety of reasons, people who are homeless may not share much about themselves… if they consent to interviews at all.

That being said, available evidence suggests that people stay in homeless shelters anywhere from two [1. “The average length of stay in emergency shelter was 69 days for single men, 51 days for single women, and 70 days for families.”] to seven months. [2. “In a survey of 24 cities, people remain homeless an average of seven months…”] (I read a paper within the last year that I now cannot find—of course—that demonstrated that the majority of people who experience homelessness are homeless for less than six months. Furthermore, of those people, most of them are homeless for only one day!)

This suggests that the majority of people in shelters do not experience chronic homelessness. Emergency shelters, then, are arguably used just for that: emergencies. Those who enter shelters obtain the help and resources (either within or outside of the shelter) to get them back on their feet. They exit the shelter system in less than a year—sometimes within a few months—and never use the system again.

However, there are individuals in shelters who meet the definition of “chronically homeless”. Some researchers have “identified that approximately 10 percent of users account[ed] for 50 percent of the annual nights of shelter provided”. [3. See page 1-10 of this document for the statistic that 10% of shelter users account for 50% of annual nights of shelter provided.] These numbers should sound familiar to those of you who follow health care policy discussions, where “5% of patients use 50% of all health care spending dollars”. [4. More about “A Small Proportion of the Total Population Accounts for Half of All U.S. Medical Spending” here.]

So what’s going on with these individuals who experience chronic homelessness? Are there risk factors for chronic homelessness? If so, what do you think they are?

Categories
Education Homelessness

What Does “Homeless” Mean?

So you’ve thought about the definition of the word “homeless”. Question: Which of the following people would you consider “homeless”?

Ms. Alfa was living in a one-bedroom apartment until the entire building burned down in a fire. She’s been “couch surfing”—spending a few nights at a friend’s apartment, then a few nights at her sister’s house, etc.—for the past two weeks.

Mr. Bravo works in the pizzeria around the corner. He’s the guy tossing the pizza dough in the window. For the past year, he’s had an agreement with his boss: He closes the restaurant every night at midnight and cleans up the shop. He can then sleep on some cardboard in the pantry until seven o’ clock in the morning.

Ms. Charlie is in jail. She was renting a room, but still has another six months left in her sentence. She has been evicted from the room because of unpaid rent. She lost her job due to her incarceration and has no other sources of income.

Mr. Delta lost his job as a construction worker after his left leg was amputated. A man pushed him onto the subway tracks when a train was approaching. While he was in a physical rehabilitation center, his landlord evicted him on false allegations. Mr. Delta was discharged from the rehab center to a men’s shelter, where he now shares an efficiency apartment with a roommate.

So? Who’s homeless?

The United Nations has offered a definition of homelessness [1. I can only find the United Nations definition of homelessness on Wikipedia]. Everyone described above would meet that definition.

The United States Code, however, has its own definition of homelessness. Here it is:

For purposes of this chapter, the term “homeless” or “homeless individual or homeless person” includes—

(1) an individual who lacks a fixed, regular, and adequate nighttime residence; and

(2) an individual who has a primary nighttime residence that is —

A. a supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill);

B. an institution that provides a temporary residence for individuals intended to be institutionalized; or

C. a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.

Ms. Alfa would NOT be considered homeless. Though she is “couch surfing”, which implies no fixed or regular housing, she is not spending her nights in a shelter, an institution, or a place “not designed for, or ordinarily used as, a regular sleeping accommodation for human beings”.

Mr. Bravo would likely be considered homeless. The pizzeria is “fixed” and “regular”, though not necessarily “adequate”. The pizzeria meets criteria 2C. Individuals who live in cars, subway stations, and abandoned buildings would also be considered homeless for the same reasons.

Ms. Charlie would NOT be considered homeless, though this is not evident from the definition provided above (see 2B). In practice, it doesn’t matter if someone loses her housing while incarcerated: If she had housing prior to jail, she is not considered homeless, even though she has no place to go upon release. The same applies to hospitalizations. [2. This is often a significant problem. Those who may need housing the most are often deemed ineligible.]

Mr. Delta would be considered homeless (see 2A).

Next: Who would you consider “chronically” homeless?

Does someone have to homeless for at least six months? one year? two years?

Would he have to be homeless for 365 consecutive days? What if he crashed at a friend’s house one week out of every month? What if he rented a hotel room when he had the money to do so?

The federal government has a definition for “chronic homelessness”, too: [3. Chronic homelessness is defined on page 3 of this document. I curiously can’t find it in the United States Code directly.]

… either (1) an unaccompanied homeless individual with a disabling condition who has been continuously homeless for a year or more, OR (2) an unaccompanied individual with a disabling condition who has had at least four episodes of homelessness in the past three years.

Compare this definition to that for “homeless” only. What’s different?

The definition for “homeless” says nothing about duration, nor does it say anything descriptive about the individual. For the definition of “chronic homelessness”, the individual must have been homeless for certain periods of time. Additionally, the person must have a “disabling condition”. [4. I’m not sure what to make of the qualifier “unaccompanied homeless individual”. Does this mean that children with a parent are not considered “chronically homeless”? That doesn’t seem right.]

The government has a definition for “disabling condition”, too: [5. “Disabling condition” is defined on page 4 of this document. I also can’t this in the United States Code.]

… a diagnosable substance abuse disorder, a serious mental illness, developmental disability, or chronic physical illness or disability, including the co-occurrence of two or more of these conditions…. [ In addition,] … a disabling condition limits an individual’s ability to work or perform one or more activities of daily living.

And that is how medicine, including psychiatry, has a role in the care of the homeless.

If you’re thinking that the definition of “chronic homelessness” suggests the medicalization of social issues, you’re not alone. If you’re thinking that medical and social issues are obviously intertwined, you’re also not alone. More on this to follow.

Categories
Education Homelessness NYC

Do All New Yorkers Have a Home?

Before I write about “homeless psychiatry”, let’s talk about homelessness.

In New York City, most people are familiar with the sight of people who are clearly homeless. These men and women, sometimes pushing carts and often saddled with several overflowing bags, are in city parks, on subway cars, and under bridges. People grow so accustomed to the homeless that, after a while, they don’t see them anymore, even if they’re looking directly at them. (Once you are actively looking for them, however, you will see them everywhere—and where they sleep, even if they aren’t there.)

Would you believe that New York City has one of the lowest ratios of street homeless individuals in the country? (Please note that there are differences between people who are homeless on the street and people who are homeless in shelters. More about this below.) In New York City, there is one street homeless person for every 2,688 people in the general population. In Los Angeles, there is one street homeless person for every 154 people. [1. See the last page of the document that compares street homeless populations of different US cities. Briefly, this data comes from volunteers who survey the city on one single night, usually during the coldest month of the year.]

What could explain this? Maybe it’s because of the cold, snowy winters and the sweltering summers. Perhaps people who are homeless leave the city and move to places with temperate climes. Those who have worked in hospitals too long might argue that many of the homeless aren’t on the streets; they’re in the hospitals. Those who work in the correctional system may make the same argument, except they replace the word “hospitals” with “jails”. Or maybe they’re hiding somewhere to avoid encounters with the police.

While those reasons may hold true for some people, one major reason that explains the low ratio of street homeless people in New York is the class action lawsuit Callahan v. Carey. The result of this lawsuit decreed that the City and State of New York must

provide shelter and board to all homeless men [and, later on, women] who met the need standard for welfare or who were homeless “by reason of physical, mental, or social dysfunction.” Thus the decree established a right to shelter for all homeless men in New York City, and also detailed the minimum standards which the City and State must maintain in shelters, including basic health and safety standards. [2. Excellent summary of Callahan v. Carey.]

As far as I know, New York is the only state where people have a legal right to shelter.

Even though New York City has a low ratio of unsheltered homeless individuals, there are many people who are homeless who stay in shelters. The Department of Homeless Services in New York (which also shares the acronym “DHS”) keeps a count of homeless individuals throughout the city.

Take a guess: How many people stay in a New York City shelter on an average night?

Those of you who have witnessed the New York City Marathon can attest to the endless waves of people who are running (plodding, whatever) in the streets. Tens of thousands of people make their way towards the finish line. About 45,000 people finished the marathon in 2010.

New York City’s Department of Homeless Services publishes the shelter census every day. The number has recently been around 37,000 people. While there is a difference between the shelter census number and the marathon finisher number, you now have a sense of the size of the shelter population.

Take another guess: How many of those 37,000 people are children?

About 16,000. [3. Statistics about the population of homeless people and children in New York.]

That’s right: In New York City shelters, there are more homeless children than homeless single adults.

These numbers tell us only about people who are willing and able to go through the process of registering for and staying in shelter beds. There are people who are homeless who either cannot or choose not to stay in shelters. [4. Here is a literary example.] As far as I know, there is no literature that describes the differences between these two populations, though I suspect that the differences are significant.

Furthermore, there are major differences between people who are homeless for a shorter period of time versus those who are “chronically” street homeless.

But before we get into those distinctions, let’s think about the definition of “homeless”. Many scholars, politicians, and advocates have tried to provide an accurate description of this word. How would you define it?