Category: Homelessness

Categories
Homelessness Nonfiction Policy

The Man in the Tiny Village.

Almost 30 minutes had passed, but The Man was still standing outside in the grey morning chill. His soiled tee shirt and loose pants hung from his tall frame. Over the next few minutes, he rarely shifted his feet while staring at a distant point on the ground.

“Hi,” I greeted again. He did not move.

“I’m worried about you,” I offered, hoping for any sign of acknowledgment. None came.

It no longer feels uncomfortable to talk to someone who doesn’t respond. Remember the people in the ICU, their bodies puffy from inflammation and fluid, their respiratory tubes hissing with each mechanical breath? Or the young men tucked into the corners of their jail cells, their heads cradled in their slender arms? Or the people so preoccupied with voices only they heard, their unblinking eyes quivering?

“I’m going to prescribe medicine for you. The goal is to help you think better. I’ll ask the staff to remind you about it. I hope you’ll try it, but if you don’t want to take it, that’s fine. I’ll see you again soon.”

His gaze remain fixed on the ground.

“It’s cold outside. Go back in,” I said. He stirred and mumbled something.

“Go back inside,” I repeated, pointing and taking a step towards his Tiny House. After a beat, he lifted a leg and meandered back to his unit.

Tiny Villages are clusters of small wooden structures, called Tiny Houses. A Tiny House is less than 100 square feet, so most people have only a bed and a storage rack inside. Each unit has heat and electricity, along with at least one window. The door locks. Outside of the two dozen or so Tiny Houses are shared bathrooms, an enclosed kitchen and dining area, plus covered laundry facilities. The houses are usually painted in bright colors. Residents often add personal touches to the small area in front of their house: Wild flowers in small pots; stickers and signs; sometimes inflatable yard decorations. Surrounding the entire Tiny Village is a wood or chain-link fence. Visitors must check in before they enter the front gate.

Village staff had introduced me to The Man about an hour earlier. When The Man opened the door to his Tiny House, the stench of body odor rushed out. For nearly five minutes he stood in the doorway and looked around at the ground. His face was scrunched up in confusion while he mumbled under his breath.

With repeated coaxing we got him out of the morning chill and into a Tiny Office. He didn’t talk to me; he instead talked with someone that only he could see. While seated in the folding chair he laughed, made animated gestures, and muttered about truth and lies. I ended our time together. We all exited the office.

Village staff pulled me aside to tell me more about The Man: Just a few months ago he was able to have a coherent conversation. Before moving into the Tiny House, he lived in a trailer. Before that, he worked in warehouses and lived in an apartment. Alcohol overuse led to problems at work and dismissals. Now he smoked methamphetamine once in a while. Other people in the Tiny Village were worried about his wellbeing, too.

It was when I was leaving the Tiny Village that I saw that The Man was still standing outside. Had he been there, motionless, for almost 30 minutes?

The medications came in a bubble pack, each row marked with the date. One pill for each day, at any time of day, for one week.

On day one, The Man popped a tablet out of its bubble, then swallowed it. Nothing changed.

The e-mail I received a week later contained exclamation points: The Man took the medicine most days that week! He was making more sense! He wanted to take more medication!

Of course I obliged.

The next time I saw him, his unit still didn’t smell fresh. However, he immediately came out and walked with us to the office.

“I’m sorry for having an attitude when we last talked,” he offered. I shook my head; he didn’t need to apologize. What he thought was an “attitude” was actually symptoms of psychosis.

When I asked him what was happening when we last spoke, he replied, “I was annoyed. People kept talking to me.”

“Who?”

He shifted uncomfortably in his chair. “I don’t want to snitch on them…”

I waited. He looked up, took a breath, and continued.

“… but I hear them all the time, 24/7, on and off, it doesn’t matter.” He shared that he had been hearing those voices since he was a kid. “Sometimes I want to tear them apart, I get so annoyed.”

What did he think of the medication? “It helps me ignore them better. When I get annoyed I take it, so I’ll take two a day.”

I nodded serenely. Thank The Universe that nothing harmful happened with his doubling of the dose!

As our time together came to a close, I asked, “Is there anything else I can help you with today?”

A moment passed. He scratched his head. He then quietly asked, “Is there anything that can help me stop using meth?”

When we bring services to where people are, they can make great gains in building the lives they want to lead.

I was worried that, because of The Man’s symptoms, we would have to tread down the road of involuntary treatment. But, the interventions and support of the team prevented this. We avoided the circus of the police and medics coercing him into an ambulance. He escaped the chaos of waiting in an emergency department while restrained to a gurney. Residing in a Tiny Home is not an ideal living situation, but at least he was able to keep the freedoms there that are absent in a psychiatric hospital.

In addition to preserving his dignity, these interventions saved costs throughout the system. First responders were freed up to attend to other emergencies. Because The Man never went to the emergency department, he never received an ambulance or hospital bill. All together that would have summed in the thousands of dollars.

This man, like the women described here, was homeless. Like them, he did not contribute to crime and disorder on America’s streets. He was not a safety threat.

Who was truly unsafe: Us, or him?

Categories
Homelessness Nonfiction Policy Public health psychiatry

Who is Actually Unsafe?

Before she and I reached the gate in the chain-link fence, a man approached us from the opposite direction. A hoodie shaded his face and his hands were in his pockets.

When she and I got closer, we waved first, all smiles. This was intentional. Hello! We are harmless, but we are paying attention!

He slowed down and pulled the hoodie off of his head, revealing the AirPods in his ears and a tentative smile on his face.

He and my colleague started greeting each other at the same time. She deferred to him.

“I’m just out for a walk,” he said. The accent in his voice revealed that English was not his first language.

“So are we,” my colleague said. This was a lie.

“Oh,” he said, his face now soft and kind. “A worker, a government worker, told me yesterday to be careful when walking here. He said that there are dangerous people back there”—he pointed to the area behind the chain-link fence—“people who are homeless.”

“Oh, okay, thanks,” we replied. His intentions were kind; he was looking out for us. He continued on to the parking lot. 

When we arrived at the gate in the chain-link fence, we ignored the sign posted on it: DO NOT CROSS.


Despite years of doing homeless outreach, I still feel my heart beat a little faster and my shoulders tense a bit whenever I approach an encampment. It doesn’t matter if it’s tucked in a wooded area, under a freeway, or behind a building.

Nothing dangerous has ever happened to me when I’ve outreached more remote locations. Sites where I have been at risk of injury were almost all public places with plenty of people milling about, or in spaces where people are literally locked in.

I don’t ignore my anxiety—our emotions are sources of information—but continue to wonder how much of my unease is due to stigma.

She and I followed the worn footpath through the overgrown grass and were soon under a canopy of leafy trees. On one branch hung a jacket that had been singed by fire. As we approached the underpass, the vegetation receded. A small river was on one side; on the other was a slope of rocks and loose dirt that led up to the concrete base of the road.

A small tent was closer to the river. A larger structure was tucked further away, just underneath the roadway. Old clothing, food wrappers, worn blankets, and other detritus were scattered about, evidence of people who were once there. Maybe they had moved on?

We saw no signs of life.

“Outreach!” my colleague called out. The rumbling of the cars overhead muffled her voice.

The small tent shifted back and forth; we heard rustling sounds.

“Outreach, hello?” my colleague called to the small tent.

“Yes, I’m coming out,” a tired voice responded. Within a few minutes, the person inside unzipped the door flap. A young woman wearing a soiled sweatshirt adorned with the name of a law school peered out. Her face was thin and her limbs were slender.

She didn’t need anything, but accepted some snacks and water. She wasn’t the one we were looking for. We wondered if she had seen The Person?

“Yeah, from time to time,” she replied. “She might be up there.”

After thanking her, we plodded through the soft dirt and climbed over wobbling rocks to the larger structure. A multi-gallon clear barrel in front of the tent was about half full of water. Nearby were piles of blankets and clothes.

The tent was wide open. There were no blankets, sleeping bags, or pillows inside. At the back of the tent was The Person. She was sleeping directly on a tarp.

The Person is not well, but aside from sleeping underneath a road, she breaks no laws. She mumbles and often says things that only she understands. In stores she quickly picks up what she wants and pays with cash and coins. 

As far as we know, she’s lived outdoors for years. And now she is over 60 years old.

These two women are homeless, but they do not contribute to crime and disorder on America’s streets. They are not safety threats.

Who is truly unsafe: Us, or them?

Categories
Homelessness Nonfiction Public health psychiatry

Opening Doors.

For our first appointment, she didn’t come downstairs. The building staff, who described her as a high-priority patient, had predicted this.

After I knocked on her door, a gruff voice shouted back, “What do you want?!”

She eventually opened her door. Inside, the room was furnished with only a bed and nightstand. The mattress still looked brand new; no linens or blankets were on it. The only item on her nightstand was a lamp, the shade still wrapped in plastic. The walls were bare; her closet was empty. Blinds kept the sunlight out.

The only personal item in her room was a flattened cardboard box. It was next to her bed. Though she had lived in that unit for almost a full year, she was still sleeping on the floor. She preferred the cardboard to the mattress.

“I don’t need anything, I’m fine, I’m fine,” she grumbled. She pointed an arthritic finger at the door before announcing, “I’m leaving now.” I stepped to the side. She hobbled past me towards the elevator, mumbling to herself. She didn’t close the door to her apartment. I did.

That first appointment was a success! Not only did she open her door, but she also spoke to me. Sure, it was a short and superficial conversation. Her primary goal, it seemed, was to get away from me. But she didn’t yell at me, despite my introduction: “Hi, my name is Dr. Yang. I work as a psychiatrist. I just wanted to introduce myself. How are you doing?”

There was a fair chance that she would talk to me again in the future. I had two goals now: Create conditions so that she would (1) talk with me again and (2) tolerate a longer conversation with me. Maybe two to three minutes next time?

Back downstairs, I tapped out a quick note:

This is a 79yo woman with a historical diagnosis of schizophrenia. She reportedly has a history of street homelessness of at least twenty years, though housing staff believe that she had been homeless for longer. She finally moved into housing about a year ago….

Categories
Homelessness Policy Public health psychiatry

Homelessness is Not a Crime.

Last week, the current Presidential administration released an executive order with a noble title, “Ending Crime and Disorder on America’s Streets.” Here is the opening paragraph of this problematic memo:

Endemic vagrancy, disorderly behavior, sudden confrontations, and violent attacks have made our cities unsafe. The number of individuals living on the streets in the United States on a single night during the last year of the previous administration — 274,224 — was the highest ever recorded. The overwhelming majority of these individuals are addicted to drugs, have a mental health condition, or both. Nearly two-thirds of homeless individuals report having regularly used hard drugs like methamphetamines, cocaine, or opioids in their lifetimes. An equally large share of homeless individuals reported suffering from mental health conditions. The Federal Government and the States have spent tens of billions of dollars on failed programs that address homelessness but not its root causes, leaving other citizens vulnerable to public safety threats.

There are misconceptions and factual errors throughout this order. (There are errors and twisting of facts in that single paragraph alone.) Dear reader, I’m just one finite person, so I will only address one problem today.

This order conflates homelessness with mental illness, substance misuse, and crime. This is wrong.

The Venn diagram below is an approximation of the reality of the intersections of homelessness, mental illness, substance misuse, and crime:

Green = Homeless; Yellow = Mental Illness, Substance Misuse; Red = Criminal Behavior; Blue = Civil Commitment

Most people are not homeless, which is why the green circle is small. Here in King County (the county Seattle is in), over 97% of people will sleep indoors tonight. Are there people who are homeless with mental illness and/or substance misuse? Of course. Did some of these people have such issues before losing their housing? Yes. Did some of them develop these problems after becoming homeless? Indeed.

Then there are all the people with a place to call home who also have mental illnesses and substance use disorders (yellow circle). In fact, many people with mental illnesses (including schizophrenia and bipolar disorder) and substance use disorders (like alcoholism, which kills more people each year than opioids) are not homeless. Furthermore, they will never be homeless.

Likewise, many people who do criminal things do not have mental illnesses or substance use disorders (red circle). If they are incarcerated, they go home when they are released from jail. Psychiatric “beds” make up only a small fraction of all jail beds. Most people who are incarcerated do not behave in ways that warrant psychiatric intervention while they are there.

The blue dot represents civil commitment, or forcing someone into an institution for psychiatric reasons. The vast majority of people with mental illnesses and/or substance misuse will never be hospitalized, let alone involuntarily committed. Some people end up in jail when they would be better served (i.e., get treatment) in a psychiatric institution.

This seems to be the worldview of the current Presidential administration:

Green = Homeless; Yellow = Mental Illness, Substance Misuse; Red = Criminal Behavior

The language of the executive order suggests that if someone is homeless, then they must have a major mental illness and/or substance use disorder. (Hence the green “homeless” circle is completely surrounded by the yellow “mental illness, substance misuse” circle.) This is wrong. It does not reflect reality.

However, as a result of this cognitive error of conflating homelessness with mental illness and substance misuse, they offer the solution of civil commitment:

Green = Homeless; Yellow = Mental Illness, Substance Misuse; Red = Criminal Behavior; Blue = Civil Commitment

Notice that the blue dot of civil commitment has transformed into a bigger blue circle that surrounds the green circle of homelessness. The memo also argues for “maximally flexible” civil commitment, which is a convenient way to keep people off the streets if homelessness equals mental illness and substance misuse (which, again, it does not).

To be clear, I am not cool with people being homeless. I ended up in public health psychiatry because there are people who are homeless because of debilitating mental illnesses and substance misuse. They get better with treatment. Then they escape homelessness — and all the challenges that come with it.

If you look at that first diagram, though, the overlap between homelessness and mental illness and substance misuse is limited. And a number of people — often people in their late teens and early 20s — don’t have any major mental health or substance use problems when they become homeless. (They are often fleeing unsafe and untenable situations in their homes.) Not knowing where you will sleep tonight is stressful. Trying to appear “normal” and “fine” makes you anxious and depressed. Worrying about unwanted attention and personal safety while outside, unsheltered, when it is dark is exhausting. No one, as a kid, thinks, “When I grow up, I want to be homeless, have a drug or alcohol problem, and need psychiatric services.” That is literally no one’s ambition.

This administration wants you to believe it’s humane — offering treatment to people with mental illness and substance use disorders. But that’s not what it’s about. It’s about hiding people who are so poor they have nowhere to live.

If this were really about providing mental health and substance use disorder support and treatment — you know, actually helping people — then the Presidential administration would not have cut $1 billion (yes, billion with a B) from the Substance Abuse and Mental Health Services Administration. The administration would not have gutted Medicaid, which is the primary funder of mental health and substance use disorder support and treatment to people who are poor, including those who are homeless.

Don’t be fooled. Pay attention.

Categories
Homelessness Policy Public health psychiatry Systems

Loud Music Is Disorder. What About Memecoins?

I read this provocative essay about “disorder” when it was first published in September 2024. I found myself alternating between nodding and frowning. It’s not a short essay, but I do encourage you to read it. (For those who lean left politically, the author is a thoughtful conservative commentator named Charles Fain Lehman, a fellow at the Manhattan Institute.) I considered writing up my reactions at the time, but I deferred. My reactions felt squishy. I didn’t have data to back up my reasons for frowning.

I still don’t have data, but the increasing disorder at the federal level frustrates me.

To summarize: Lehman opens by citing statistics that crime has indeed fallen in the US. Many Americans, though, feel that crime is rising both in their communities and across the nation. He then argues that “disorder” is increasing and offers these as examples of “disorder”:

  • A man blasting loud music from his phone in a subway car;
  • Teenagers spray-painting graffiti on a public park;
  • A large homeless encampment taking over a city block;
  • A man throwing his trash on the ground and walking away;
  • A group of women selling sex on a street corner.

From this, he proposes a definition for “disorder”: domination of public space for private purposes.

He goes on to argue that engaging in disorderly behavior is the rational choice, but most people do not contribute to disorder. Why? He attributes this to

“social control”—the regulation of individual behavior by social institutions through informal and formal means.

Lehman says that the Covid pandemic, in particular, weakened social control (e.g., fewer “eyes on the street” due to increasing remote work; reduction of law enforcement numbers due to the George Floyd murder and defund the police efforts). He adds that “the core to combating disorder is restoring public control of public space.”

To his credit, he doesn’t offer law enforcement as the sole solution. Lehman briefly describes changing the environment with intention (e.g., broadcasting deterrent music, putting pressure on landlords to clean up spaces). But, once informal efforts fail to restore order, then formal systems must intervene. In his view, law enforcement is the primary formal system.

Most of my professional work has been with people experiencing homelessness and mental illness. But I’m not actually cool with people living outside. I feel discouraged and unsettled when I see tents blocking lengths of sidewalks. When I see people slumped on the sidewalk due to fentanyl, my first thought is, “I wish you would stop using drugs.” I am not a fan of disorder.[1]

I like Lehman’s definition of disorder. While not comprehensive, “domination of public space for private purposes” is a reasonable starting point.

What I don’t like is how many of his examples are associated with poverty (homeless encampment; prostitution; loud music on public transit, a space rarely used by wealthy people). Yes, these are visible and common examples of disorder. But what about the disorder associated with people with wealth and power? Just because we don’t see it every day doesn’t mean people with money and influence are paragons of morality. Why no commentary on that?

Is it disorder when the President visits golf resorts that he owns? He profits from his Secret Service detail staying in his hotels. Isn’t that the domination of public funds (our tax dollars!) for his private, profit-building purposes?

Likewise, is it disorder when the President and his wife launch their own memecoins? Isn’t their use of public office to collect millions of dollars a form of disorder?

Is it disorder when the deputy chief of staff in the White House redirects ICE agents to enact his own anti-immigration agenda?

Is it disorder when the federal administration cuts millions of dollars from scientific research funding because language in the grants references race, gender, and sex? Isn’t this the domination of public resources for a private, anti-DEI ideology?

Is it disorder when the federal administration wants to cut billions in Medicaid funding so that people with extraordinary wealth will get tax breaks? How is that not domination of public resources for private purposes?

None of these actions had occurred by September 2024. Regardless, I wonder if Lehman had considered the intersection of power with his definition of disorder. Lehman says early on in his essay that

critics [contend] that disorder is just another word that the powerful use for whatever it is the non-white, poor, and otherwise marginalized do.

This criticism, combined with Lehman’s omission of power, illustrates who does and does not get to define “disorder”.

We are seeing nauseating abuses of power in this Presidential administration. If blasting music on a bus is disorder, but funneling public money into personal projects is not, then we’re not defining disorder. We’re excusing power.

[1] I am a fan in believing that people can change. And they do! People stop drinking and using drugs. They start taking medication, and they learn how to manage their symptoms sooner. Again, just because we don’t see that change every day doesn’t mean it isn’t happening.