The Plight of the Triple Challenged by Wayne M. Mellinger, Ph.D.

THE PLIGHT OF THE “TRIPLE CHALLENGED”: 

UNDERSTANDING AND HELPING PEOPLE EXPERIENCING HOMELESSNESS, SERIOUS MENTAL ILLNESS AND SUBSTANCE USE DISORDERS 

 By Wayne Martin Mellinger, Ph.D. 

DRAFT JULY 2024 

A version of the paper was presented to the NAMI Public Policy Group in July 2024, 

moderated by Lynne Gibbs

INTRODUCTION 

 Dual diagnosis, also known as co-occurring disorders, refers to the presence of both a mental health disorder and a substance use disorder in the same individual. These disorders can interact with each other, making diagnosis and treatment more complex. If that individual happens to be unhoused, they may be extremely vulnerable with poorly understood and complex needs. I call these individuals “the triple challenged” because of the three major obstacles they face. 

 For a variety of reasons those who are unhoused and experience both serious mental health challenges and substance use disorders seem to catch everyone’s eyes and may seem like they are “everywhere”. So common do they appear in our society that the dominant stereotype of unhoused people is that all unhoused people are people who experience mental illness and who use substances. Elsewhere I have explored this “crazy bum mythology” and the “us / them thinking” that leads people to create these inaccurate and demeaning stereotypes of the homeless (Mellinger 2023). 

 The prevalence of co-occurring disorders is four times greater among people who are unhoused than among the general population. These numbers are based on estimates and vary according to the definitions employed. The actual prevalence of the triple challenged in our society, while still disturbing common, is but a small proportion of the total unhoused population. 

 Allow me to discuss the numbers in my local community. Santa Barbara County, where I live, has a total population of about 500,000 people, out of which about 2000 are unhoused. That is 0.4% of the total population is unhoused (about 1 in every 200 people). Of the 2000 unhoused people about 30% (600 people) have serious mental health disorders and about half of those, or 15% of the total unhoused population (300 people) are dually diagnosed. The triple challenged are thus 0.06% of the population (1 out of 1667 people). 

 The current situation of the “triple challenged” is extremely bad. Last year the US Conference of Mayors called the mental health crisis impacting our nation’s unhoused populations “America’s No 1 Problem”. How did we get here? Last November in Noozhawk I explored the origins of this crisis, writing: Two public health emergencies — the COVID-19 pandemic and the opioid overdose epidemic — have collided with two negative social trends — California’s housing and mental health care crises — to greatly impact a marginalized population that wasn’t doing that well psychologically even in the best of times. I noted how even in ordinary times the mental health of the unhoused is broadly marked by a mass psychology of despair, in which stress, loneliness, depression, anxiety and boredom are pervasive. 

 In my many interviews with people living on the streets of Santa Barbara and in our shelters, I find a population worn down by months and months of endless suffering. People's understandings of the "triple challenged" – those facing homelessness, serious mental illness, and substance use disorders – are often very poor. Cultural myths surrounding homelessness, mental illness, and substance use collide to create a distorted picture. The "crazy bum" stereotype paints all homeless individuals as mentally ill and unwilling to help themselves. This not only ignores the vast array of reasons someone might become homeless, but it also fuels stigma and discrimination against those with mental illness. Similarly, misconceptions about substance use disorders often portray them as moral failings rather than complex medical conditions. This lack of understanding creates a significant barrier to seeking help and reinforces the cycle of homelessness for the "triple challenged.” 

 This paper aims to dismantle the cultural myths surrounding homelessness, mental illness, and substance use. By deconstructing these misconceptions, we can cultivate a clearer understanding of the "triple challenged" and their experiences. This understanding is crucial for developing effective support systems that empower them to transition off the streets. My own journey through psychological breakdown, addiction, and homelessness has instilled in me a profound belief in the possibility of growth and fulfillment even amidst hardship. 

These experiences have transformed me from a wounded individual into a "wounded healer," equipped with empathy and a resolute desire to serve my community. Through this paper, I hope to bridge the gap between societal perceptions and the lived realities of the "triple challenged," paving the way for a future where they can heal, reach their full potential, and contribute their unique wisdom to the world. 

 HISTORICAL BACKGROUND 

 To understand contemporary homelessness, it's important to investigate its historical roots. The first wave of urban homelessness in the United States arose after the Civil War. Returning veterans and freed slaves, facing discrimination and limited opportunities, competed for scarce housing in emerging industrial cities. Many southern states enacted "vagrancy laws" criminalizing unemployment, foreshadowing the long history of race, poverty, and criminalization intertwined in this country. 

 By the early 20th century, most major cities had "skid rows" with short-term, dormitory-style "flophouses" catering to a largely male population of seasonal laborers. Women and children on the brink of homelessness often found refuge through charitable religious organizations. However, urban renewal projects in the 1960s demolished many skid row boarding houses, further displacing vulnerable residents. 

The 1950s to 1970s saw the deinstitutionalization of large mental health facilities due to new anti-psychotic medications. While these institutions faced criticism for inhumane conditions, the dismantling of the system without sufficient community-based support left many vulnerable individuals at risk of homelessness. 

Federal budget cuts to public housing starting in the Reagan era, combined with the mass incarceration of the War on Drugs that disproportionately impacted Black and Latino communities, further exacerbated the issue. The resulting "new homeless" population of the 1980s included more women, families, and minorities, who often lacked access to shelters or other forms of housing. Since then, the cost of housing has skyrocketed, and gentrification has displaced low-income residents from opportunity-rich areas.

Today, the lack of affordable housing remains a major factor, compounded by domestic violence, divorce, inadequate mental health and addiction treatment, and the impact of trauma. While the perception persists that homelessness is a personal failing, this simplistic view ignores the complex social and economic forces at play. Every person's experience is ultimately unique, shaped by their individual circumstances and external factors. 

 UNDERSTANDING THE TRIPLE CHALLENGED 

The plight of those facing homelessness, mental illness, and substance use disorders (the "triple challenged") is often misconstrued as a problem of individual failings, rather than a consequence of systemic issues. This focus on individual blame ignores the broader social, economic, and political forces that shape homelessness. Here, C. Wright Mills' concept of the "sociological imagination" becomes crucial. The sociological imagination encourages us to look beyond a person's immediate circumstances and delve into the historical, social, and economic factors that influence their lives. In the case of the "triple challenged," it compels us to examine not just individual choices, but also the broader societal structures that create and perpetuate homelessness. 

The individualistic approach tends to explain homelessness as a result of personal flaws – poor choices, lack of willpower, or laziness. This perspective ignores the complex interplay of factors like poverty, discrimination, mental health issues, and lack of affordable housing. While personal choices can play a role, they often occur within a context shaped by structural forces. 

Structural forces are the underlying social, economic, and political systems that create and maintain inequality. These forces are largely outside of an individual's control and have a disproportionate impact on certain groups. For example, the decline in affordable housing, cuts to mental health services, and the criminalization of homelessness are all structural factors that contribute to the rise of the "triple challenged" population. 

By understanding the interplay between individual experiences and structural forces, we can move beyond victim-blaming narratives and develop effective solutions. 

PEOPLE EXPERIENCING MENTAL ILLNESS 

 Mental illnesses are a diverse group of complex conditions characterized by significant disturbances in thinking, emotional regulation, or behavior. They have varying causes, symptoms and experiences and often result in distress and impairment in important areas of functioning, such as social interactions, work performance, or daily activities. Life on the streets is a harsh reality, characterized by constant stress, violence, and a lack of basic necessities. 

These constant challenges can exacerbate symptoms of mental illness, making it harder for individuals to manage their conditions, adhere to medication, and engage in therapy. This creates a negative cycle where life on the streets worsens mental health, while mental illness makes it even harder to secure stable housing. 

 In any given year, 25% of the American population will experience some form of mental illness (This holds true for youth also). About 50% of people who have a diagnosis have more than one. Most people (66%) will not seek treatment due to stigma. In any given year, the percentage of the population 18 years of age and older experience the following mental disorders: 

Mood Disorders (Major Depression, Bipolar Disorder) 9.5% 

Anxiety Disorders (Panic Disorder, PTSD, OCD and Phobias) 18% Psychotic Disorders (Schizophrenia, Schizoaffective) 1.1% 

Substance Use Disorders (including alcohol) 17.3% 

Eating Disorders (Anorexia Nervosa, Bulimia Nervosa) ` 3% 

 While 5.5% of the general population suffer serious mental illness (S.M.I) up to 26% of the unhoused population have SMIs. 

 Diagnosing mental illness is a complex process primarily involving comprehensive clinical interviews, but supplemented by standardized assessments, psychological tests, and sometimes brain imaging. Diagnosing mental illness among unhoused people who use substances presents an additional challenge. The effects of substance use can mimic symptoms of mental illness, while mental illness can increase the risk of substance abuse. "Street medicine" programs have emerged as a crucial response to this challenge. Multidisciplinary teams of healthcare professionals, including nurses, social workers, and sometimes psychiatrists, reach out to unhoused individuals, providing primary care, medication management, and mental health support directly on the streets or in shelters. 

 The history of psychiatry is marked by evolving models and theoretical approaches. The rise of the biomedical model, focusing on biological explanations and pharmaceutical interventions, gained dominance in the latter half of the 20th century. This shift has been criticized for overemphasizing biological factors and neglecting the roles of social determinants, individual experiences, and personal agency. 

While medication plays a central role in many cases (e.g., antidepressants for depression), treatment goes beyond pills. Psychotherapy, various therapeutic approaches, and lifestyle modifications (healthy sleep, exercise, and diet) are integral parts of treatment plans. However, concerns exist regarding the influence of pharmaceutical companies on the development and marketing of medication. Mental health treatment isn't a one-stop solution. The continuum of care encompasses various levels of support, ranging from early intervention and prevention programs to outpatient therapy, residential programs, and in some cases, involuntary hospitalization. 

Psychiatric institutions encompass a spectrum of settings (outpatient clinics, day treatment programs, residential treatment facilities, and psychiatric hospitals), with the type and level of care tailored to individual needs. Despite the crucial role of mental health services, access remains a major barrier for many. Stigma, lack of affordable insurance, and limited availability of providers in certain areas contribute to this inequity. For the homeless population, accessing services presents even greater challenges: stigma, distrust in the system, transportation difficulties, identification issues, and complex bureaucratic procedures can all be hurdles. Additionally, traditional services are often not designed for the unique needs of the unhoused population. A significant barrier to recovery is the lack of sustained and integrated treatment for individuals with co-occurring mental illness and substance use disorders (dual diagnosis). 

Traditionally, these conditions have been treated in separate systems, creating a fragmented approach that makes it difficult for individuals to receive comprehensive care. Supportive housing models have emerged as a promising approach to tackling homelessness among those with mental illness. This approach prioritizes getting individuals housed first, then providing wraparound supportive services, including mental health care, addiction treatment, and case management. Studies have shown that supportive housing significantly reduces homelessness rates and improves mental health outcomes. “Housing First” approaches, in which people with active mental health challenges and who still use substances are placed directly into housing, have proven to be more successful than other approaches that demand sobriety and stability as a requirement to get housing. 

 Mental health is not just an individual issue, but also shaped by social determinants like poverty and discrimination. For people living on the streets with serious mental illness, a holistic approach is essential. This includes getting them into housing, accessing supportive services and benefits, and reconnecting with support networks. We must address the root causes of mental illness alongside providing supportive housing and treatment to truly help those facing the "triple challenges" recover and lead stable and healthy lives. 

 SUBSTANCE USE AMONG THE TRIPLE CHALLENGED 

 Myths portraying all substance use as a personal failing ignore the complex realities faced by the "triple challenged" – those experiencing homelessness, mental illness, and substance use disorders. Substance use is shaped by a web of social, economic, and structural factors, including poverty, trauma, and limited access to healthcare. In a desperate attempt at self-medication, many struggling with homelessness, mental illness, and substance use disorders (the 'triple challenged') turn to substances to cope with the unrelenting hardships of their situation. Substances like alcohol, methamphetamine, and heroin can offer a temporary escape from emotional pain and a sense of belonging within a marginalized community. 

The desire to find pleasure and escape hardship is a significant motivator that shouldn't be dismissed. However, the criminalization of homelessness and punitive drug policies exacerbate these challenges. The war on drugs disproportionately targets marginalized communities and creates cycles of incarceration and recidivism. Similarly, our broken mental health system often leaves people with limited access to culturally-competent care and integrated treatment models crucial for the "triple challenged." Stigma surrounding mental illness further discourages individuals from seeking help, potentially leading them to self-medicate with substances. 

 The stereotype of the "dangerous" and "untreatable" addict not only hides the diversity of experiences but also erases the possibility of non-problematic substance use. Moreover, labeling everyone as an "addict" can hinder effective treatment approaches. Outreach efforts for substance users on the streets are often minimal. While harm reduction programs like needle exchange and naloxone distribution exist, there may be limited access to safe injection sites, psycho-education, and culturally-competent treatment options. Long wait times for residential treatment (e.g., 30 days in Santa Barbara) and demanding requirements (daily phone calls) further create barriers to access. 

 Moving forward, addressing substance use among the "triple challenged" requires a shift from blame narratives to compassionate, person-centered approaches. We must prioritize harm reduction strategies, culturally-competent treatment models, and readily available support services. Only by acknowledging the complex realities and systemic inequalities that contribute to their marginalization, and by addressing the root causes of poverty, trauma, and social isolation, can we offer the "triple challenged" the holistic support and integrated treatment they deserve. 

 THE REVOLVING DOOR PHENOMENON 

The "revolving door" phenomenon describes the cycle of individuals repeatedly entering and exiting the criminal justice system, often involving incarceration followed by release back into the community without adequate support. This problem is particularly acute for dually diagnosed individuals experiencing both mental illness and substance use disorders, who are disproportionately represented in the homeless population. Dually diagnosed individuals on the streets often engage in survival behaviors that may be criminalized, leading to frequent arrests and short jail stays. 

 Fragmentation and lack of coordination between mental health and addiction services make it difficult for these individuals to access the integrated treatment they need. Upon release, the lack of affordable and supportive housing options often leads them back to the streets, increasing the risk of relapse and re-arrest. Unmanaged mental health symptoms like psychosis or mania can lead to behaviors that are misconstrued as criminal, resulting in arrests. Individuals may use substances to cope with their mental illness, leading to substance use disorders and related criminal activity. Activities necessary for survival on the streets, like panhandling or public intoxication, may be criminalized, pushing them towards the justice system. The revolving door is not only a human tragedy but also an immense financial burden. The costs associated with arrests, incarceration, and emergency healthcare for this population significantly strain social services and law enforcement budgets. 

 The causes of the revolving door phenomenon are many: Lack of coordination between mental health, addiction treatment, and housing services creates gaps in care and hinders continuity of support; inadequate funding for mental health and addiction treatment programs restricts access to these services for vulnerable populations; stigma surrounding mental illness and substance use disorders discourages individuals from seeking help and can hinder their reintegration into society. The lack of treatment exacerbates mental health and addiction issues, leading to further physical and emotional decline. Repeated involvement with the criminal justice system can limit employment opportunities and housing options, hindering social mobility. Individuals trapped in the revolving door are more vulnerable to violence, victimization, and premature death. 

 TREATMENT OPTIONS FOR THE TRIPLE CHALLENGED 

Despite the fact that stable housing is crucial for long-term recovery for those facing homelessness, mental illness, and substance use disorders, the current housing crisis often necessitates starting treatment on the streets. The best practice for outreach is multidisciplinary teams (MDTs), containing such diverse professionals as mental health counselors, addiction specialists, case managers, nurses, and housing specialists. These teams are able to assess mental health needs, substance use patterns, and potential risks. This information helps connect individuals with appropriate services. 

 The best practices for the treatment of co-occurring disorders are sustained and integrated programs that address both mental health and SUDs simultaneously. These programs typically use evidence-based therapies like Cognitive Behavioral Therapy (CBT) and Motivational Interviewing (MI) to address the underlying causes of both conditions. Medication-assisted treatment (MAT) combines medications like methadone or buprenorphine with therapy to manage SUDs, reducing cravings and relapse risk. 

 Other best practices for the “triple challenged” include trauma-informed care, cultural competent services which acknowledge and respect the diverse backgrounds and experiences of individuals, and a continuity of care ensuring seamless transitions between different treatment elements. Getting off the streets is paramount to the recovery of those with mental disabilities who are unhoused. Many communities now use the HUD-mandated “housing first approach” which prioritizes providing stable housing without preconditions, offering a foundation for addressing mental health and addiction issues. 

 For this population “supportive housing” can be essential as it combines affordable housing with on-site support services like case management, mental health counseling, and addiction treatment. Both housing first and supportive housing can integrate peer support services, providing individuals with guidance and encouragement from those who have experienced similar challenges. 

 CONCLUSION: BREAKING THE CYCLE 

 A profound gap exists between our cultural myths and common-sense understandings of homelessness, mental illness, and substance use, and the stark realities faced by those living with these challenges. This paper has endeavored to bridge this gap by examining the complexities that contribute to the struggles of the "triple challenged." Mental illness presents a complex and multifaceted challenge in the 21st century. Understanding the diverse landscape of mental well-being, recognizing the limitations of diagnosis, and fostering a holistic approach that incorporates various treatment options and social interventions are crucial. By moving beyond stigma and ensuring equitable access to mental healthcare, we can work towards a future where individuals have the support they need to thrive. 

The intricate relationship between mental illness and homelessness presents a complex challenge, yet it is not insurmountable. By acknowledging the historical context, understanding the barriers posed by the current system, and embracing innovative approaches, we can work towards a future where both mental health and shelter are attainable realities. Early intervention and preventive measures are crucial. Expanding access to mental health services in schools and communities can identify potential issues early and offer support to prevent individuals from falling into crisis and eventually onto the streets. Investing in Integrated Systems: A fundamental shift towards integrated systems is necessary. Breaking down silos between mental health and addiction treatment can provide individuals with co-occurring disorders with seamless, comprehensive care. Including the voices of individuals with lived experience in designing solutions is paramount. Collaboration between mental health professionals, social workers, and individuals who have experienced homelessness can lead to the development of more effective and humane services. Supportive housing models have proven their effectiveness. Increased investment in building and maintaining such programs, while ensuring access to quality mental health and addiction treatment within those structures, can significantly reduce homelessness rates and improve overall well-being. 

Combating homelessness and mental illness requires a collective effort. Social safety nets need strengthening to ensure basic needs are met for everyone. Engaging communities in outreach programs and fostering a climate of understanding can help individuals reintegrate into society. The path forward necessitates a multifaceted approach, one that addresses the complex needs of the unhoused population with mental illness. By prioritizing prevention, investing in integrated care, empowering individuals, and building supportive structures, we can create a future where the cycle of homelessness and mental illness is broken, and individuals are empowered to reach their full potential. A critical gap exists in the realm of substance abuse psycho-education for those experiencing homelessness. Understanding the connection between substance use and mental health is crucial for recovery. Many unhoused individuals with mental illness use substances as a form of self-medication, numbing their emotional pain. Without addressing the underlying issues and providing effective psycho-education on the dangers of self-medication, both mental health and physical health will remain compromised. 

REFERENCES 

Bourgois, P., & Schonberg, J. (2009). Righteous Dopefiend. University of California Press. 

Mellinger, W. (2012, January 15). Triple Challenged Can’t Grapple with Their Demons Alone. Noozhawk. Retrieved from Noozhawk website. 

Weinstein, D. (2010). Of Others Inside: Insanity, Addiction, and Belonging in America. Temple University Press.