Although I did not intend for this to be a series, this is the third article I have written about homelessness. I also wanted to say a few words about mental illness, as I am close to several people so diagnosed. This came up during commenting on one of the previous articles, and I felt that it needed to be discussed in more detail than the comment structure allowed. My two previous articles about homelessness on this site were Where Do Americans Live? and Ask Not What the Homeless Can Do for You, Ask What They Can Do for Themselves.
This is a much too brief article to allow for more than a thumbnail sketch of mental illness and why homeless people are at a greater risk if they have certain disorders. Nor is it an exposé on drugs and street living, but rather a look at how the three come together. Please use the links provided, and your own searches on the topics, to better educate yourself.
Most, if not all, people suffer from the effects of mental disorders to some extent. Perhaps suffer is too strong a word for what many people consider to be personality traits or quirks. Consider someone you believe to be anal retentive; everything has to be just so, or they may be disturbed when their routine is out of kilter. Mostly we adjust to them and their ways, and manage to get along. But, this could be more than just quirkiness; it might be a manifestation of obsessive-compulsive disorder (OCD).
Another example would be people who seem grumpy or grouchy much of the time, which might be symptomatic of dysthymia (a mild form of depression) or one of several other mood disorders. Not liking to speak in public is a fairly common quirk but could be seen in people with a mild specific phobia, or other anxiety disorders.
Psychiatrists and psychologists have diagnostic criteria for all of the disorders and usually some way of scaling or rating them by the effect they have on a person’s life (read more about disorders at PsychCentral). To be considered as affected by a disorder, the symptoms usually have to be continuous for several months, and in some cases up to one year. This graph shows the incidence of the five major disorder areas in the 12 month, and lifetime prevalence categories used by professionals. Prevalence is the extent to which the disorder is felt over a specific time period.
In myself I can see what I call the edges of several disorders. I am slightly OCD; I sometimes feel the need to check to make sure I’ve locked a door, or turned off the water or the stove. Mostly, I don’t check, but occasionally it nags at me. Now, imagine that you can’t control the urge to check the stove, or you feel compelled to wash your hands, multiple times, for hours, until they chap and bleed.
I am also slightly autistic, which was much more of a problem when I was younger. Then, I felt the need to count things; people, tiles or bricks, passing cars. I seem to have mostly outgrown that but another trait seems to have stayed with me. When reading, and sometimes during other solitary activities, I rock back and forth, just slightly, or tap my foot, fingers, or shake my leg. Mostly I don’t even realize that I am doing it, but frequently my wife notices. This is not something that generally disrupts my life, but I see it as another edge of a disorder. Picture not being able to stop the compulsions, rocking and counting; this is one aspect of full-blown autism.
This chart lists the most common of more than 400 mental disorders and their frequency. Most people with a disorder don’t hear voices or see hallucinations; those types of extreme cases are very rare, occurring in less than one percent of the population. Major depressive disorder, specific phobias, and alcohol abuse top the list, all over 10 percent. Other common disorders ranging in frequency from two percent to <10 percent are: ADHD, PTSD, drug abuse, bipolar disorder, and panic disorder. Many of these are rare enough that most people never encounter them.
I believe that all humans exist on a continuum consisting of many of these disorders. The World Health Organization believes that as much as 30 percent of the world population meets the criteria for a mental disorder at some point in their lives. If you study the characteristics, or the diagnosis criteria, of say, OCD you will see many of them in people you know, or yourself. This doesn’t mean that these people need treatment via drugs and counseling; sometimes just the awareness that they have these traits can be enough for them to overcome what many consider to be personality faults. In the two examples about myself, it is clear, at least to me, that these are very low on the continuum.
I know of several people diagnosed with a variety of mental illnesses; to some of whom I am very close. One of them is bipolar, and has had extreme mood swings for over 20 years. The biggest problem with bipolar disorder is that during the manic phase they are higher than anyone on any recreational drug ever has been. Although I have never read this in medical publications, I suspect that this feeling is just as addictive, and perhaps more so, than any street drug. Why would we expect that this addicted person would willingly give up their high?
But herein lies the rub: the depression that follows these highs is so very low. Most people have experienced mild depression, from losing a job to a loved one passing, and most people rebound back to a normal emotional level fairly quickly, but imagine being ten or a hundred times that depressed. The bipolar sufferers must be on the medication at all times to prevent going into a perhaps fatal depression. If left to their own devices, the manic personality will demand that high with no thought to the resultant consequences. Many of them then self medicate to try and alleviate the depression, usually with street drugs or alcohol. Either of these will add their own set of problems that do not mesh well with their ailment. This article, “Self-medicating: When the Cure IS the Disease”, has some more information about comorbidity and dual diagnosis.
Having two or more disorders is known as comorbidity and occurs very frequently with some disorders. Perhaps the greatest comorbid disorders are substance abuse, and either anxiety or mood disorders, being twice as likely as in those not using drugs. There are four risk factors associated with this comorbidity: genetic vulnerabilities; environmental triggers; developmental effects; and the fact that similar areas of the brain are involved. A recently recognized comorbid connection was found between substance disorders, and perhaps not surprisingly, post-traumatic stress disorder (PTSD). In one recent study 23 percent of over 9,200 patients were found to have three comorbid diagnoses.
Another person I know has a panoply of diagnoses: antisocial personality disorder, which causes them to completely disregard the feelings of others; borderline personality disorder, similar to bipolar in that they have mood swings but more important is the unstable sense of identity and difficulty with interpersonal relationships; narcissistic personality disorder, prompting unrealistic fantasies, requiring constant attention, lacking empathy; panic disorder; and in my opinion, schizophrenia, because of the observed paranoia, social withdrawal, and drug use (as many as 50 percent of schizophrenics abuse drugs). These are some very troubling diagnoses and also very hard to live with, but mostly manageable with the proper use of medications and therapy.
At this time, neither of them is homeless, but the situation for them, and for others suffering from many types of mental disorders, could change at any time.
Although substance abuse is considered to be a mental disorder, I think it deserves a few separate words. This is an epidemic in almost every sense of the word.
- Increased virulence: the purity and availability of many drugs have increased dramatically.
- Introduction into novel settings: meth has moved into small towns throughout the U.S.
- Changes in host exposure and susceptibility: younger children are being exposed to drugs every year.
Don’t you think that more than 20 million users, or over 6 percent of the U.S. population constitutes an epidemic?
If that is not disturbing enough, then how about over 600,000 ER visits every year, or more than 50,000 deaths attributed to illegal drugs, at a cost of over $160 billion a year from the federal budget. I’m not sure if I understand why one of the only areas in which the U.S continues to lead the world is in illegal drug use.
There are two commonly used definitions for homelessness: “Not having customary access to a conventional dwelling” and “living in public or private emergency shelters; or in the streets, parks, subways, bus terminals, rail stations, airports, under bridges or aqueducts, abandoned buildings, cars, or in any public or private space not designated for shelters.” Neither of these definitions addresses every possible situation, nor can they be expected to encompass every one in just a few words. But regardless of the official definition, we know homelessness when we see it.
The total number of homeless is nearly impossible to estimate, since there is no place where they are known to be at any given time. Several different counts have arrived at around 1, 500,000 people as of 2011. The map on this blog shows the national distribution, with most populous states and cities having the most homeless.
I mentioned in my previous article that a major concern that had come to the attention of the United Nations was a lack of clean, safe water. This, and the lack of proper sanitation facilities are adding a third factor to the overall problem; traditional diseases.
The single greatest cause for homelessness is lack of affordable housing, whether it is from foreclosure, loss of public assistance, or because some other need is more pressing than the rent. The most common composition of homeless families is a mother with one to two children. It shouldn’t be surprising that in this situation, food or medical care for the children is more important than housing. One in fifty children in the U.S. will experience homelessness in their lifetime; and they will be twice as likely to go hungry, or have health problems as adults, and have less than a 25 percent chance of finishing high school.
In most cities there are shelters which can provide at least temporary accommodations, but these are neither permanent nor do they provide any sort of medical or therapeutic treatment. There are programs, such as the Homeless Outreach Project in New York and other cities, which have helped a significant number of the homeless living in city parks into treatment, entitlement programs, and temporary housing. The greatest limiting factor is still permanent housing, but below are links to the outreach project websites for San Diego, Los Angeles, Denver, Kansas City, Chicago, Philadelphia, New York, and Miami. There isn’t room here for an exhaustive list, but if you want to help, there are places that need it.
Mixing the Three
One question to consider is whether a homeless person is more likely to have a mental disorder, or substance abuse problem, before or after becoming homeless. Not surprising, to me at any rate, is that there is no clear understanding of this question; it is almost classically, a chicken-and-egg problem. Unquestionably though, if people like these are living on the street, without even basic medical treatment, especially those with a high probability of comorbid diagnoses, without the specialized drugs and counseling usually needed, how can they be expected to even cope, much less improve?
Another disturbing aspect of this whole situation is the appalling number of veterans who are among the homeless. One estimate indicates that more than 10 percent of the total number of homeless people were in the military, down from as much as 30 percent in 2004. Back to the chicken/egg, are they homeless because of PTSD, or does the homelessness exacerbate the PTSD? Use these links for more on veterans and PTSD.
One of the most significant issues in getting help for the homeless who are also mentally ill and/or substance abusers, is facilities that can handle the complex interconnected problems. A run-of-the-mill shelter is not set up to give treatment or therapy for either case. Drug rehabilitation clinics usually don’t have psychiatrists or psychologists trained in mental health issues. What is needed is a facility that does have all necessary people and equipment in one place.
Problem or Solution
I had said in my second article on this topic that one solution to the homeless problem would be to house them in their own village, with necessities such ashousing, food, education, training, and most importantly, medical care, supplied . The long term goal of this program would be helping to reestablish them into normal society. Furthermore, I suggested that if deemed appropriate, this newly trained group could, repay if you will, by working on state or federal infrastructure projects, a la President Roosevelt’s CCC or WPA programs. Those were effective not only in allowing millions of unemployed to work and earn pay, but also provided dams, highways, national parks, and other large scale projects.
One of the reasons that I thought my plan had merit was because it allows maximum resource utilization. We do this all of the time; a team is dispatched to tackle a fire, not a lone fireman. Likewise, we collocate certain facilities as in hospitals; doctors, pharmacy, radiology, and surgery. I propose the same sort of thing: for housing, it’s like a hotel with all needed services in one place; for food, it’s like a restaurant with storage, refrigerators, stoves, cooks all in one place; for training, as in a school, with instructors and training materials all together; and exactly like in a hospital, for medical needs. How can it not make sense to do these things all in one location, instead of spread out in several locations, with volunteers trying to get back and forth, without all of the things you need to make it work, not at hand?
There were, and of course will be, detractors to this plan, saying that this would be just another ghetto, or that it sounded like a Dickensian work-house. Certainly, if care is not taken and a multiyear or even multidecade plan is not established, including funding, then it could turn out that way. Any program is only as good as the people working on it, intentions notwithstanding; we know where good intentions lead.
I just don’t think this is possible on a small scale, which is what is happening now. Volunteer organizations, church groups, scout troops, compassionate individuals are all trying to help, but in many cases it is just too little. As I said above, this needs to have resources, which are too expensive and too spread out, which are organized in the most efficient way possible.
I don’t see how we can consider these people crazy; we are the ones who have the means to fix this, and we don’t.