Category: Homelessness

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Homelessness Lessons Nonfiction Observations Reflection

What Would It Be Like to Say Hello?

My first memory of encountering a person who appeared to have no place to live was during my first year of college at UCLA. A man was sitting outside a mini-mart, his legs crossed and his hair long. He looked tired and his clothes had stains on them. Feeling pity for him, I went into the mini-mart and purchased a turkey sandwich on wheat.

“Here,” I said as I handed him the sandwich. I beamed with Warm Fuzzies for Doing a Good Deed. “Take this.”

Because I expected him to thank me for My Act of Generosity, I was dumbfounded when he started yelling at me with contempt: “A sandwich? I don’t want that sandwich. I don’t like turkey and I have an allergy to gluten. If you really wanted to help me, you’d buy me a meal at an all-you-can-eat place. What am I going to do after I eat a sandwich? I’ll still be hungry. At least I can get another plate of food at an all-you-can-eat restaurant.”

“Okay,” I said, my cheeks burning with shame. He had a point: All hungry people prefer all-you-can-eat food to what now looked like a pathetic turkey sandwich. I took the rejected sandwich back to my dorm room.

My dining companion and I were seated at a long table that looked out a large window. Across the street was a man who we often saw in the downtown shopping district. He often carried a unrolled sleeping bag on his shoulder while talking and growling to himself. His clothes were soiled and too big for him. The soles of his shoes were falling apart. He didn’t have a beard, only uneven facial stubble. His eyes were light and his face was dark from smears, smudges, dirt, and dust.

“He doesn’t look well,” I said to my dining companion. The man was sitting on his rumpled sleeping bag on the sidewalk while engaged in an animated conversation… with no one. Sometimes he leaned back against the side of the building and puffed on a cigarette.

“I wonder when he last ate,” I wondered aloud.

“Why don’t you buy him something to eat?”

“Because he might not want that. Some people feel shame when people just give them food. They don’t like that other people think that they don’t have enough money to buy food for themselves. And I don’t even know what kind of food he wants. When we’re done eating, let’s go over there and ask him.”

As we approached him, his posture was relaxed and he was about halfway through his cigarette. His clumpy hair was falling into his eyes and everything he was wearing was soiled. He was engrossed in a conversation, occasionally making a point with his right hand.

“Excuse me?” I asked.

He continued talking.

“Excuse me?”

He stopped talking, turned his head, and looked at me. He remained still as the swirls of smoke from his cigarette defied gravity with ease.

“Hi. Do you want some food?”

Another tendril of smoke dissolved into the night before he answered: He shook his head no.

“Are you sure?”

He nodded yes.

I smiled and waved good-bye. I heard him resume his conversation as we walked away.

In retrospect, I should have introduced myself and asked him for his name. And I wonder if, next time, he will be hungry and accept an offer of food.

Sometimes we believe people are so different from us. How could there be anything similar between that guy talking to himself and sleeping on the street and me? What do I have in common with that guy wearing dirty clothes and carrying a sleeping bag around?

Well, we all share the wish to be treated with dignity. We want people to acknowledge us, our presence, our existence. We want people to see us as equals, not less than. We want people to show us respect, to see us as people who have worth.

Maybe you see someone in your daily commute who sleeps outside or doesn’t seem to have any money. Maybe it’s someone who sits against a wall with a sign asking for help.

What would it be like if you said hello that person? Or made eye contact with that person and smiled? What would it be like to acknowledge that person as a person? What’s gotten in the way of you doing that in the past? What is the worst thing that could happen if you tried that? What’s the likelihood that your worst fear in this situation would come true?

What would it be like if we said hello to everyone in our communities? Because aren’t these individuals who sleep outside and talk to themselves part of our communities?

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Funding Homelessness Nonfiction NYC Policy Reflection Seattle Systems

God’s Work versus Meaningful Work versus Value.

Every now and then, when some people learn what kind of work I do, they say, “You’re doing God’s work. Thank you.”

They mean well, so I accept the compliment, though I also tack on, “I also like what I do. It’s meaningful work for me.”

So many of the people I see, whether in my current job or in my past jobs working in other underserved communities, have a lot going on that psychiatry and medicine cannot formally address. One example is housing. It is often an effective intervention for the distress of people who don’t have a place to live, though housing is not something physicians can prescribe. However, there are individuals who are eligible for housing, but do not want to move into housing for reasons that do not make sense to most people. For example, in New York I worked with a man who would spend his days sitting in front of the building where he once worked before he became ill. He talked to himself and burned through multiple packs of cigarettes. He did not recognize how soiled his clothes and skin became with time. At night he disappeared into the subway tunnels and rode the trains. He did not want to move into an apartment until he was able to get his job back, even though he hadn’t worked there in over ten years. With time (nearly two years!) and unrelenting attention, our team was able to persuade him to try living indoors. He eventually accepted the key and moved in.

There are other active conditions that I do not have the skills to treat: Sometimes it’s institutional racism; sometimes it’s multiple generations of poverty. Both prevent people from accessing education, housing, and other resources. Do some of these individuals end up taking psychotropic medications due to the consequences of these systemic conditions? Yes. Do I think they’re always indicated? No.

Most of my jobs have been unconventional: I worked on an Assertive Community Treatment team that often provided intensive psychiatric services in people’s homes. I worked with a homeless outreach team and did most of my clinical work in alleys, under bridges, and in public parks. I worked in a geriatric adult home and saw people either in my office, which was literally the storage room for the recreational therapist’s stuff, or in their apartments if they were uncomfortable seeing me in the storage room. I was recruited to create and lead the programming for a new crisis center whose goal was to divert people from jails and emergency departments.

And now I work in a jail.

As time progresses, it has become clear to me that I have not had the typical career for a psychiatrist. I like that. However, I often also feel out of touch with my colleagues. I believe that they are all trying their best, but they don’t have the time to see how systems end up failing the most vulnerable and ill in our communities. They work in the ivory towers of academia and don’t seem to realize the dearth of resources—financial, administrative, academic—in the community. They work in private practice and don’t seem to realize how ill some people are and how we need their expertise. They work in psychiatric hospitals and seem to believe that some of these individuals will never get better when, in fact, they do.

Because much of my work has been outside of the traditional system, I consider myself fortunate that I have been able to escape the box of simply prescribing medications. Many of the individuals under my care do not want to take medications. Their desire to not take medications, though, doesn’t stop us from working with them. We meet them where they are at and remember that they are, first, people. As we are in the profession of helping people shift their thoughts, emotions, and behaviors, we believe that there will come a time—maybe soon, but maybe not for weeks, months, or years—that something will change. Just getting someone to talk to us becomes the essential task. This is true whether someone is in a jail cell, living in a cardboard box under a bridge, or residing in a studio apartment.

Should systems pay psychiatrists to do this work? Maybe it’s not “cost effective” because of its “low return on investment”. After all, this task of “building rapport” means psychiatrists aren’t working “at the top of their licenses”. If a psychiatrist is able to get people to talk to her and help them shift their behaviors, whether or not that involves medications, does that have value?

Does the psychiatrist’s efforts have value if it helps the “system” save money?

Is there value if it reduces the suffering of these individuals who have had to deal with police officers, jails, and living on the streets due to a psychiatric condition?

Perhaps my idealism blinds me. One of my early mentors in New York City often said, “I want the guy who lives under the Manhattan Bridge to have a psychiatrist who is as good as, if not better than, the psychiatrist who has a private practice on Fifth Avenue.” I couldn’t agree more.

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Homelessness Nonfiction Observations Seattle

Street Scenes.

The woman walking in front of me on the sidewalk was wearing a short skirt and a sleeveless blouse. After stepping out of the street he readjusted the strap of the large duffel bag on his shoulder and began to drift towards her. Uneven stubble covered his face and his hair stuck out in several directions.

“Hi,” he said, smiling with both his eyes and lips. “How are you?”

She swept past him without turning her head. Unfazed, he then saw me.

“OH, COME ON!” he exclaimed, his voice more delighted than annoyed. He clearly recognized me.

As he continued to grin at me, I offered, “Hi.” I know you, too…

“Hi! How are you?” he greeted, his voice warm and his eyes bright.

“Fine, thank you. How are you?” You were one of my patients, but from where…?

“I’m good, thanks. It’s so nice to see you!” Neither one of us stopped walking, though he slowed down just as I began to cross the street.

I waved good-bye to him. He waved back.

Oh! I last saw you in jail! You thought you were a machine! You told me that everyone could read your thoughts! You shouted at the walls of your cell—

—and how much better you look now![1. The moment someone changes out of a hospital gown or a jail uniform into casual clothes he will immediately look more healthy, independent, and dignified.]

My father was telling me a story as we walked past the corner store. I’m not sure if he saw the man approach me.

“Hey, can you spare some change?”

Turning my head with a small smile and looking at his face, I said, “No.”

“Oh, hey now,” the man said, starting to walk next to me. He then reached out and stroked my arm. “I just want to touch you.”

“DON’T TOUCH ME!” I shouted, still walking. The man stopped. My father, taken aback, looked at the man over his shoulder, though remained silent.

“Go on,” I said lightly to my father, who then did. However, I didn’t hear anything he said. Did that actually just happen?[2. In my years of working with people who are homeless it has been rare for anyone to touch me. This includes people who were actively psychotic or acutely intoxicated. Furthermore, when people have touched me, it was within the bounds of social convention: We shook hands, gave high fives, bumped fists. Hence my alarm after this man touched me.]

The yellow sign on the fence reads: “Illegal activities and loitering not permitted.”

Within the confines of the fence are at least ten tents arranged in a half circle. Some are reinforced with several layers of duct tape. Others are covered with blue tarps.

A small barbecue grill, round and uncovered, is in the center of the circle.

A freeway ramp is on the other side of the fence. Trucks with 18 wheels, cars running on electricity alone, clunkers painted different colors, sleek sedans with round logos, and vans carrying kids, groceries, sporting equipment, and DVDs roll past.

The camps have grown this year.

Categories
Education Homelessness Observations Reflection Systems

Do People Choose to be Homeless?

One of the things we talked about during dinner was whether people choose to be homeless.

“Yeah, it seems like some people want to be homeless,” he said.

“No… I don’t think so,” his friend replied.

They looked at me.

I cannot speak for all people who have ever been homeless. However, I have several years of experience working with people who were homeless and refused housing again and again[1. When working within a housing first model, the goal is to give people housing without any expectations that people will participate in mental health or substance abuse treatment. The goal is really just to get them inside.], as well as people who left their housing and returned to the streets.[2. In my experience, people who leave housing usually return to street homelessness. Most do not return to the shelter system.]

Thus, I believe that people who are homeless do not want to be homeless. They usually have concerns about the housing offered to them.

Here are some reasons people have shared with me when I have asked them why they don’t want housing:

I can’t move in anywhere. I have to stay outside. The aliens say that if I move in anywhere, they will exterminate me. I’ve already been exterminated three times. I don’t want to get exterminated again.

I don’t want to live inside. It never feels safe. Bad things happened to me when I’ve been inside. It’s too hard to get away.

But I don’t need your housing. One day my boss will hire me again–I was really good at my job–and when I start working again I can pay for my own apartment. (This man, for years, sat on the sidewalk across the street from the building where he said he previously worked.)

There’s too many rules: Curfew at 10pm? No guests? What if I want to bring a lady friend over? Nope. Don’t want to deal with all that.

I know that place. There’re too many people using dope. I know what’s gonna happen if I am around that crowd. I’m trying to stay away from all that.

That place? Isn’t that where all the crazy people live? No, thank you–I don’t want crazy neighbors.

If I could move in without giving my name or social security number, then, yes, I’ll move in. But people keep asking me for personal information and I don’t know what the government will do with that.

So, the reasons people give generally fall into three categories:

  1. People want freedom and don’t appreciate the constraints of rules.
  2. People are concerned about their safety within the building. These reasons may or may not have any basis in reality.
  3. People may feel some guilt or shame related to the housing (whether they deserve it, what it would mean if they moved in, etc.).

It’s hard for those of us who have a stable place to live[3. One consequence of working with people who are homeless is that you never stop giving thanks that you have a place to live. You don’t have to worry about where you’re going to sleep that night. You don’t have to worry that someone might try to rob you or set you on fire. You don’t have to worry about the police picking you up simply because you have nowhere else to go. These are the things we all take for granted.] to understand why some people seem to “choose” to live outside. Sometimes people point to Maslow’s hierarchy of needs and ask, “But isn’t housing a physiological need? People need water, food, and shelter. Why would someone ignore this basic need?”

Yes, shelter is a basic need. However, people who live outside can and do meet their basic needs, including shelter. They sleep in abandoned buildings, underneath bridges, in tents, in covered doorways, in wooded groves, in bus shelters, etc. These are not ideal places to live, but they’re sufficient.

No one wants to be homeless. What they want is psychological safety. For those individuals who decline housing, sometimes the need for psychological safety will override what seems like the “logical” choice of accepting housing.

People continue to astound me with their resilience. When people resist housing for years, though, it makes me wonder what happened to them that resulted in this resilience.

Categories
Homelessness Nonfiction Observations Seattle

Simple Pleasures.

People hung hammocks between trees and suspended their disbelief in novels. Cyclists rolled past, talking to each other over their shoulders. Parents pushed sleeping babies in strollers while sipping iced coffees and slushies. Couples held hands and shielded their eyes from the afternoon sun. It tossed silver glitter onto the blue water of the bay.

Not a cloud was in the sky: Mt. Rainier loomed white and massive to the south. The Olympic Mountains, also capped with snow, rose in the west, its jagged ridges carving a grey-blue line on the horizon. Trees full of green leaves covered the islands in the distance.

The man was wearing baggy pants and dirty work boots. Over this was an oversized and puffy winter parka, tattered at the edges and the hood pulled over his head. A duffel bag that was half his size hung from his left shoulder; as he walked he listed to the right to maintain his balance. People gave him wide berth as they walked past him. He held his head low.

He dropped his bag on the boardwalk and sat down. Sitting against a post, his back to the brilliant sun and shimmering water, he zipped open the duffel. From it he pulled a brown paper sack. He used one hand to rustle through the contents within.

He pulled out a small item wrapped in white. With expectation on his face he opened the package. Leaning back, he took a bite from the chocolate-covered ice cream bar. A small smile crossed his lips.