Category: Reflection

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
Nonfiction Observations Reflection

Baseball Rituals.

Prior to attending a minor league baseball game recently, I learned about racing events that occur at certain ballparks:

“Baseball is so schlocky,” I said after viewing a YouTube video of the Presidents with their oversized heads teetering along the perimeter of the field. “No other professional sport has anything like this.”

“That’s not true,” my husband replied. “They throw octopuses onto the ice in hockey.”

After learning that, indeed, there is a Legend of the Octopus, I still expressed skepticism: “Could you imagine a whole bunch of sausages running around on a football field?”

“Football has cheerleaders,” my husband retorted.

Good point.

The mascot was busy at the minor league baseball game. Not only did Rhubarb the Reindeer hustle around the stadium with a flag at the start of the game, but he also came out in boxing regalia at one point and, later, wearing a dress shirt and slacks, “performed” a Talking Heads song.

A few rows behind us a man with a voice rattling with gravel shouted at the players:

This is baseball, not first base ball!
Communicate!
Boring!

His son started shouting similar things at the players. When we turned around to see who they were, we realized that the higher pitched voice did not come from his son; it came from his wife.

When the 7th inning came around, we all stood up and sang “Take Me Out to the Ballgame” in different keys. I then ate some Cracker Jack.

I wondered if all this schlock these rituals are meant to appease our short attention spans. Ball 1, ball 2, strike 1… the man with the gravel in his throat shouts unsolicited advice, people get up to buy hot dogs and beer, the bugle calls “Charge!” It’s hard to wait. We want stuff to happen.

Then I wondered if these rituals give us simple comfort while everything else changes. Even if my boss doesn’t give me enough time or credit for the work I do or my wife is angry at me for reasons I think are ridiculous or my kid is not meeting my academic expectations or my friends are worried I have a drinking problem or my boyfriend has hit me twice this week or I lost all of my savings at the casino or my sister died in a car crash last month…

… at least I know that I can caterwaul “Take Me Out to the Ballgame” in the 7th inning, Rhubarb the Reindeer will dance on top of the dugout, and the pierogies will race.

Categories
Nonfiction Observations Reflection

Grief.

Shortly after my mother died, a coworker asked me about grief: “What does it feel like?”

I remember looking at her and feeling confused. What does it feel like…?

Words like “terrible”, “awful”, “really sad”, and “numb” didn’t seem quite right. Elements of all those adjectives were true, but none of them captured the fine texture of grief.

“It feels like… a really bad breakup,” I finally said. As the words came out of my mouth I realized that wasn’t quite right. It was also an inane comparison.

“Huh,” she answered.

Nine months later, I found words to describe my grief: It feels like my heart is falling.

During moments of stillness, those spaces between exhalations and inhalations, I feel my heart physically dropping. It is an endless fall; there is no bottom.

I remain surprised with how close to the surface the grief lives. I don’t cry when I talk about my mother’s death. Yet, when people ask me about her, I feel my face scrunching up the way faces do when people are about to cry. The sensations in my face remind me of that week she was in the hospital, when I smiled during the day and wept at night, asking God and the Universe questions that nobody could answer.

Though the tears do not come, my face suggests they will. And I know that the person listening to me sees it. It’s like when you blush: You feel your cheeks flash with heat and hope that the other person won’t make fun of you for it.

Emotions always shift, though: Sometimes, in my mind’s eye, I set an imaginary table and place a pot of steaming tea and two cups on it. I invite Grief to sit down and have tea with me. Grief never declines. I ask Grief how it is doing. Grief never says anything in response, but we sit in silence and enjoy our tea together. When Grief is ready, it leaves.

And then I notice that my heart is no longer falling.

Almost 11 months have passed since my mother died. Since I found words for my grief, my heart doesn’t feel like it is dropping as often. Maybe the time I needed has elapsed; maybe the sensation of my heart falling doesn’t overwhelm me as much as it used to.

Maybe by showing Grief some kindness and acceptance with imaginary tea it has also shown kindness to me.

Categories
Medicine Observations Policy Reflection Systems

On “Mental Illness”.

I’ve been invited to speak to a group of attorneys who work at the interface of psychiatry and the law. The topic of my talk? “Psychiatry 101.”

A psychiatrist who gave this talk to a similar group a few years ago advised me: “You should assume that lawyers are laymen. It’s surprising how little they know, given the work that they do.”

This teaching opportunity to teach has given me pause: What is mental illness?

Most of my work has been with people with few resources (no home, no job, etc.) or with people who are experiencing symptoms that cause significant distress (they won’t eat because they think all food is composed of their internal organs; they often try to kill themselves due to hearing voices telling them to do so; etc.). Most people would agree that these individuals have “mental illnesses”, whether “caused” by their circumstances (imagine people trying to set you on fire or rape you because you are sleeping outside) or by apparent biological events (imagine a freshman in college with an unremarkable history who, over the course of months, begins to believe that the government inserted a chip into his brain).

I have also worked in settings where:

  • a wealthy man’s wife felt overwhelmed with anxiety about which of their three homes they should remodel first
  • a aerospace engineer with no symptoms wanted to try an antidepressant because his girlfriend started taking one and she now seemed to have greater clarity of mind; “maybe that will happen to me, too”
  • a college student felt depressed because his parents wanted him to pursue a professional degree, but he didn’t want to do that

Do those individuals have mental illnesses? Does psychological suffering equate to mental illness? Even if they are able to get on with the necessary details and difficulties of life?[1. Do not misunderstand: People with means can and do have mental illnesses. Take the software developer who was certain that public surfaces were contaminated with exotic diseases; he couldn’t get himself to go to work or spend time with friends due to fears that he would get sick and die. Or the accountant who, if she doesn’t sleep enough, would believe that she is the mother of God; she went to hospitals insisting that she was in labor with Jesus when, in fact, she was not pregnant.]

My mind then spins to recent events, such as the Germanwings place crash. Many people have argued that, because the co-pilot killed people, he was mentally ill. He apparently had a diagnosis of depression, but I agree with Dr. Anne Skomorowsky that a diagnosis of depression alone does not explain why he committed mass murder.

But if he was mentally ill, what diagnosis would best describe his condition? What do we call it when people kill other people? Is that behavior alone sufficient to say that someone is mentally ill? If so, what do we make of:

  • soldiers killing other people during war
  • gang members who, without provocation, shoot police officers or other gang members
  • suicide bombers
  • parents who kill their newborn infants because the babies aren’t the parents’ desired sex

Does a person’s intentions affect the definition of “mental illness”? (How good are we at reading the minds of others? We often assume intention when observing behavior. And those assumptions can be way off.) Does the situational context also affect what a “mental illness” is? (When in Rome, do you do as the Romans do? What if you don’t know what Romans do?)

People have surmised that people who kill other people may have conditions such as antisocial or narcissistic personality disorder. However, these designations are still problematic: Not everyone with those personality disorders kill people.

Perhaps this is why I prefer to work with people who demonstrate behaviors that undoubtedly impair their function.[2. It is easier for me to work with people who demonstrate clear evidence of “impairment in function”. Part of this is due to the greater ease and clarity in diagnosis: If someone’s symptoms are within the spectrum of normal human experience, then diagnosis is unnecessary. Part of this is also due to treatment: Some interventions in psychiatry—specifically medications—are not benign. Furthermore, it is unclear how some—many?—psychotropic medications work. We first must do no harm.] I am reluctant to describe most people as “mentally ill” because some behaviors that people find bizarre have helped the person cope with their circumstances. The people who always wear masks or scream on the street? Those behaviors may have somehow protected them in the past—even if it means that the general public derides them for being “weird”. It seems unfair to say someone is “ill” when what they have done before in the past has given them some degree of protection. (To be clear, I don’t necessarily apply this formulation to people who have committed murder. For example, I can’t think of how flying a plane into a mountain could ever be an adaptive coping skill.)

Words matter. I’m not sure that I have more clarity yet about what I should teach, though it is clear that I should focus on how I phrase the information I present.

Categories
Education Lessons Medicine Nonfiction Reflection

We Want to See Them Better.

When he and I first met he told me that he had a doctoral degree in psychology, was the CEO of the jail, and could speak 13 languages. To demonstrate, he said, “Hong tong ching chong lai tai!” He then punched the door to his cell and shouted, “GET THE F-CK OUT OF HERE, B-TCH!”

I did.

The next week, he answered my questions about the pencil drawings on his walls.

“My name is John Doe,” he said, the words spilling out of his mouth. “You all think my name is Peter Pan, but it’s not. It’s John Doe. See my name up there?” He pointed at the “John Doe” he had written in two-foot high letters on his cell wall. “That’s my name. My people call me John Doe. I am the leader of all the people. I am the leader of all the Asians. I am half-Asian.”

Nothing about him looked Asian.

More weekly visits occurred.

“I can speak 13 languages,” he said again. “Tingee tongee tai tai—;”

“You’re making fun of me,” I interrupted.

“I’m not,” he said, smiling. I’d never seen him smile before.

“No, I’m pretty sure you are.”

“I’m not. Aichee aichee—”

I walked away.

“Hey! I’m a doctor! I own the jail! I CONTROL ALL OF THIS!” he shouted at me.

I kept walking.

One week I was trying to speak to a man in a nearby cell. John Doe was shouting: “The police are pigs! They don’t know anything! I hired all of them! I own them!” His vitriol bounced off of the concrete surfaces of the cell block; I couldn’t hear anything but his reverberating voice.

“Excuse me,” I said to the man. John Doe was still shouting when I arrived at his cell door. He fell silent.

“Could you please not yell for ten minutes so I can talk to another guy here?”

He nodded.

“Thank you,” I said, returning to the man.

Two minutes later, John Doe started yelling again. I sighed.

“That John Doe—he really pushes my buttons. I don’t know what it is about him—people have said and done much worse things, but there’s something about him….” I said in exasperation to my colleagues. “I mean, I know he’s ill, but…!”

He declined to take medications. He followed his own prescriptions of daily showers, three meals with extra fruit if he could get it, and daily bodyweight exercises. He rarely slept.

Another week the same situation occurred again: I wanted to talk to another man in the same cell block as John Doe, who was shouting.

John Doe stopped yelling when he saw me approach his cell.

“Could you please not shout for ten or fifteen minutes so I can talk to another man here?” I asked, resisting the urge to shout at him.

He nodded. I didn’t say “thank you” this time.

I completed my interview with the other man. John Doe remained silent the entire time. I was surprised.

“Thank you for not yelling. I appreciate it,” I said to John Doe on my way out. He nodded.

As I walked out of the cell block, I heard him shouting again.

More weekly visits occurred. John Doe still declined to take medications. He stopped speaking to me in faux-Asian languages, though would occasionally speak in gibberish that I did not understand. He stopped shouting whenever he noticed that I had entered the cell block.

“You’re not a real doctor,” he said one day. “You must be a nurse.”

“What makes you think that?”

“You’re a woman. Women aren’t doctors. Maybe you’re a clinic assistant. A really smart clinic assistant. But you’re not a doctor. Women can’t be doctors. I’m the president of all the doctors and hospitals. I own all the hospitals and jails—”

“Okay. Is there anything I can help you with today?”

A few weeks later, John Doe was no longer in jail. A judge declared that he wasn’t competent to stand trial due to his psychiatric symptoms. He went to the state hospital to receive treatment.

More weeks passed. He eventually returned to jail once his competency was restored, but he didn’t return to psychiatric housing. My colleagues who evaluated him upon his return, however, shared news about John Doe with enthusiasm.

“He’s taking meds now and he’s better. He’s polite. He answers questions. He doesn’t talk in fake languages. He doesn’t shout. I mean, he’s not warm or friendly and he doesn’t talk much, but he can hold a conversation. He’s definitely better.”

“What?” I exclaimed. “Are you serious?”

I wanted to see him. I wanted to see him better.

Despite that, I never did: He would not have found my visit therapeutic or helpful. The only person who would have felt better after that visit was me.

One of the greatest rewards in health care is helping and seeing people get better. This is particularly true when people have severe illnesses. We want to see them better. It gives us hope that other people who have comparable symptoms—symptoms that scare us, worry us, sadden us—will get better, too.

“How will [action x] change your management?” That’s a question we often talk about. If that lab study won’t change what you do, don’t order the lab. If the patient’s answer to your question won’t change how you proceed, don’t ask the question.

John Doe was no longer my patient. He was better. I didn’t need to see him to believe it.