Triple Challenges: Homeless, Mentally Ill and Addicted

Triple Challenged: Homeless, Mentally Ill and Addicted

by Wayne Martin Mellinger, Ph.D.

To put yourself in another person's shoes you gotta first unlace your own. In our increasingly cosmopolitan world, our ability to imagine how other people think and feel is an essential social skill. Especially if these people live vastly different lives from our own. Empathy requires openness, self-awareness and a willingness to suspend judgment. Thankfully, it can be learned and becomes easier with practice.

My topic is what I call the “triple challenged”--people who have mental health challenges, live on the streets, and have problems of substance abuse and addiction. In this period of economic recession, with the ensuing cuts in funding for social services, many of our nation's cities are flooded with people fitting this description.

I happen to live in Santa Barbara, California, a wealthy coastal community 90 miles north of Los Angeles, with a regional population of about 160,000 people. One year ago we could count 1,040 homeless people in the region. Over the course of an entire year we can estimate that up to 3,000 people will experience homelessness on the South Coast of Santa Barbara County. About half of those on the streets have mental health challenges and about half of them also have substance abuse issues. That is perhaps around 750 people.

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I would like you to put yourself into someone else's shoes for a moment. Imagine going through life in sixth gear, sometimes flying smoothly on the interstate of life. Other times this accelerated mode of being leads to reckless driving in which you drive off the road and terribly crash the car. While other people start their days slowly and gradually warm up their engines, you often lie in bed at night already awake and raring to go.

While raised to be polite and deferential, you constantly find yourself interrupting people and finishing their sentences. You often feel like you have bulldozed your way through an encounter. Excited about what you are talking about and filled with optimism and creativity, you sometimes accomplish great deeds and charm the world.

Other times you sense that you are all over the place, ideas firing in your head so fast that others cannot keep up. Sometimes, you feel more than self-assured and your euphoric states turn into grandiosity. You even get unrealistic beliefs about what you can accomplish. Some times you are involved in “pleasurable sprees” that afterwards seem terrifyingly foolish.

Now imagine that you have found something that soothes that excessive energy and calms you down so much that you are actually able to sit quietly and focus for hours on doing some of the things you enjoy, like doing artwork. While you know that the substance is unhealthy and illegal, the relief that you feel under its influences is so wonderful that you find ways to do it more and more, until you are so involved with the substance that you are chemically dependent. This form of “self-medication” is a way that you have learned to calm yourself down, cease the non-stop flows of ideas and engage in the peaceful activities that you love so much.

This is one scenario of what a “co-occurring disorder” looks like. That phrase is used by medical professionals to discuss situations in which a person has a psychiatric disorder as well as an addiction. Also referred as “dual diagnosis”, huge advances have been made in learning how best to help these people. While we know some of the “best practices” to help those with co-occurring disorders, communities are often slow at implementing them.

For a very long time, those professionals who deal with mental health challenges were very reluctant to take on people with drug and alcohol problems. Similarly, those who work in substance abuse rehabilitation were reluctant to work with clients with mental health challenges, who often needed to take psychopharmacological medicines.

For a long time the myth, frequently perpetuated by some in Alcoholics Anonymous, that substance abusers needed to cease the intake of all mind-altering substances to be in “recovery”, prevailed. We now know that “integrated treatment” in which both the psychiatric disorders and addiction are dealt with simultaneously is the best practice.

The above scenario describes my own challenges with bi-polar disorder and my self-medication with methamphetamine. When I first got “clean and sober” I did not understand my compulsions to use high powered stimulants. Luckily, good mental health professionals recognized my symptoms and I was prescribed medicines which stabilize my mood and calm me down to such an extent that I no longer feel compelled to do illicit drugs.

Fact: 30-60% of patients with bi-polar disorder have substance abuse problems, more than any other Axis I psychiatric disorder.

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I never woke up one day and said,”Hey I want to lead a tragic life”. My journey with mental health challenges and addiction have lead me to loose everything in my life more than a couple of times—my jobs, my housing, my books and files, and my self-respect.

While I come from a loving and caring middle-class family that provided me with everything that I needed and ensured that life opportunities would abound, an undercurrent of darkness and chaos has run through my life. Periods of intense creativity, intellectual pursuit and professional accolades get followed by periods of exhausted depression, isolation and dysfunctionality. These episodes have lead me to homelessness several times in my adult life.

One curious thing for me is how we so easily see things in others that we cannot see in ourselves. As a social worker for the homeless I specialize in working with those with co-occurring disorders, never recognizing my own challenges. While I knew that people on the streets, suffering years of traumatic abuse, often engaged in the form and level of self-care they understood best, I never recognized my own forms of self-care.

My last relapse brought me to me knees, and lead me to want to probe deeper into the underlying reasons for my ongoing substance abuse issues. Seeking psychiatric help, I confronted my issues and learned that I had bi-polar disorder. This has lead me to be even more sensitized to the flight of others with what I consider the “triple challenge” of homelessness, mental illness and addiction.

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The other evening while I was strolling in downtown Santa Barbara when a car filled with young people drives up alongside an older, somewhat disheveled man reaching into a garbage can. They honk their horn, startling the older man, and scream out of the car “Hey Hobo! Get a job! Stop being a sponge!”. Given the way he was talking to himself animatedly I assumed that he might have some untreated mental health challenges.

In American society those who live without homes are seen as lazy, as feeding off the system and as a “problem” in themselves. Social scientists and survey researchers confirm these attitudes among American generally.

Most Americans see homelessness as the outcome of personal choices and / or qualities of being. In our society people are deemed responsible for their own economic fate. This individualistic orientation is seen in the reasons people give to survey researchers when asked “why are there poor people in this county?” People tend to emphasize personal traits, such as lack of effort, thrift or talent as the determining factors which lead to poverty, and minimize the structural factors (such as corporate downsizing, lack of jobs, or poor schools).

Research on the homeless mentally ill acknowledges both types of causes: structural and individual. Examples of structural causes include trends in poverty, the housing market, the structure of the economy generally and social policies. Overall, structural barriers are societal—they point to the ways that social systems operate and are outside the control of the person.

If the unemployment rate rises, that is a structural cause of homelessness. If the amount of available and affordable housing goes down that is a structural cause of homelessness. If the amount of affordable rehabilitation services for drug and alcohol treatment goes down, that is a structural barrier for those with substance abuse problems who want to get off the street. If a community's mental health services or low-income housing agencies have policies and procedures which make services difficult to obtain, confusing or inaccessible to those with severe mental health challenges, these can be structural barriers.

In contrast, individualistic causes focus on personal behavior, and can often result in “blaming the victim”. Examples of perceived individual causes include substance abuse and lack of a work ethic. If people give up hope and stop trying to get off the street that is probably perceived as an individual cause of homelessness.

Clearly, individual and structural factors interact with each other and are often related. For example, alcoholism and other drug challenges are typically perceived as a personal problems. Many people who have had substance abuse issues have gone through treatment, continue to work on their recovery and are currently “clean and sober”, thus demonstrating how personal choices can change. But if the help needed to get off drugs and alcohol are absent, or not affordable, or are inaccessible treatment, that is a structural barrier.

People who have these “triple challenges” constantly recycle though a life on the streets .and in and out of health care and the criminal justice systems without getting the integrated treatment programs they need. Recently a Santa Barbara Grand Jury Report severely criticized the services of our local mental health agencies stating that our jail had become the de facto central mental health institution of our community. It demanded changes in this archaic and dysfunctional system.

Those who have both mental health and addiction issues are the most difficult to stably house and treat due to limited availability of integrated mental health and substance abuse treatment.

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Next time that you are walking down the street and someone who appears to be homeless approaches and asks you for money imagine for a moment what it might be like to be penniless, with no personal possessions but the things in your backpack. Imagine what it is like to sleep outside, to not have access to showers and all the amenities of bathrooms, to constantly have people avoid interactions with you, and call you a “bum” or a “derelict”.

Imagine what it might be like to have clinical depression, or panic attacks, or to hear voices in your head, or to think that the FBI is surveilling you through remote controlled birds. Imagine having these mental health challenges go untreated for decades. Imagine being a part of a subculture in which “partying” with various substances is somewhat normal and acceptable, and access to them is easy. Imagine living a lifestyle in which encounters with law enforcement officers is frequent and spending time in jail is common, often for “petty stuff” like sleeping outdoors, having an “open container”, urinating in public or being in possession of marijuana.

If you have never really talked to a person who has mental health challenges or who lives on the street I recommend highly that you do so. It is really only by getting close to others and hearing their stories that we can learn to take their perspective. While hearing the stories of our neighbors on the streets, and how they have coped with the variety of life challenges they have is important to understanding their perspective, the plight of the “triple challenged” is not best understood at the individual level.

We must locate the structural transformations that lie behind their personal troubles. By translating personal troubles into public issues, we see the societal changes that have shaped our lives and theirs. We look for causes beyond the individual level and resist “blaming the victim”. For example, the closing of the large state-run mental health institutions in the 1970s left many severely mentally ill people with no where to go. To look at an issue in this way is to have what C. Wright Mills called “a sociological imagination”.

And, while helping individual people navigate the difficulties of their lives is important, to improve the situation for those on the streets we must advocate for structural changes in how society operates at the institutional level.

Listening to the story of someone on the streets, who might be barely holding onto the cliff of life, you can see many the flaws in how American society works. You might be reminded of how the wealthiest nation in the world has no safety net to catch those who free fall to the bottom. You might imagine what it would be like experience such a fall.

All of our lives are intertwined and we must act accordingly. That person asking me for a quarter is my brother or sister. I might not know them personally. But I know dozens of people just like them. While I might not have much money in my pocket to offer them, I can give this person eye contact and a smile. I can acknowledge their presence. I can ask how their day is going. I can listen to what they have to say. I can say a kind word.