Homelessness: The Unkindest Cut of All

Caroline Ridout Stewart, LCSW

Homelessness

A few years back I received a painful Facebook post from our dear New PATH Florida representative, Julia Negron, stating that individuals in a town in Florida had been arrested and jailed for feeding the homeless. This was a particularly provocative post for me as my own son, who suffers from a co-occurring disorder, and who has in the past been homeless, was told by our neighborhood Vons that he was not permitted in the store. He had been found in the grocery store bathroom eating a bag of chips. When I first learned that my son was evicted from Vons and that my husband had been scolded and shamed by the security guard there for assisting our son, I was embarrassed and angry with our son for stealing. That being said, I realized that I had once again fallen into that mean-spirited, judgmental place blaming the homeless for all that happens to them. I suspect that my son had, indeed, stolen the bag of chips because he was starving. He was horrifically thin and wasting away. His pants slid off his hips readily. He might also have spent too much time in the restroom because he was on opioid replacement therapy which causes intestinal problems. Imagine the quandary of being homeless with no restroom available! Because of my own too quick to judge response to learning that my son had been evicted from his home store, I have subsequently given a great deal of thought to my own psychotherapy practice where I work with parents of homeless adults most of whom suffer from a complex combination of psychiatric illness and substance use disorders. My son is currently housed during COVID-19 following two years in sober living.  However, despite having secure housing, his father and I find ourselves puzzled by his attraction to his homeless encampment community.  Last night, he spent the night with a friend in his RV which we all know will soon be towed. I am no fool. Our son’s hours of Zoom AA meetings are not filling the terrible hole in his desire for social connection and a shared mission.  Sadly, I believe that there are some essential, concrete, measurable reasons why our streets are occupied by the homeless in increasing numbers.

It seems to me that there are at least two primary systemic players in the American failed effort towards the homeless:  The homeless individuals, themselves and the non-profit agencies and their staff. Of course, our American embrace of the puritanical belief that any one of us could be rich and successful if we only worked hard enough, sadly impacts the situation but that is subject of a future essay.

Regarding the homeless, themselves and their contribution to the problem: I know for a fact that my son, on a warm and sunny day, prefers homelessness to another round of overly-institutionalized care. He has been in a myriad of residential drug and alcohol treatment facilities and he pines to be free of other adults always telling him what to do, when to get up, when to sleep, what to eat, and how to spend every hour of his day.  I often think of my friends with chronic illnesses who have to return again and again to the hospital. They tell me how much they hate the institutionalization there.

Adding to my son’s institutional fatigue, is my son’s long-standing problem with impaired executive functioning. He, like many of his fellow homeless comrades, finds himself often not even knowing what day it is. He lives for the moment and always has. For many who know of my academic work, you know that my son is a “hunter”, one who is strategic, in the moment and incapable of future-orientation. Is he a hunter by birth, accident, illness or addictive illness? In my son’s case, almost all of these issues contribute to his organizational deficits. How does poor executive functioning contribute to homelessness? Well, permanent housing has two minimal requirements; either a high degree of future-orientation and tolerance for frustration or money, plain and simple. My son has neither. Doing well in school, a job, even working with a social service agency in a sequenced and collaborative way, requires executive functioning. What is a person to do without such a skill? While our son is currently securely housed, it is wholly due to our parental financial support and, literally, hours and hours of parental shepherding with regards to rent payments, doctor’s appointments, pharmacy pick-ups and maintaining order in the apartment.

Ironically, there are many who now argue that substance use disorders are the outcome of anomie and social estrangement or what we might call a social disorder more than a chemical disorder.  I say ironic because one thing my son loves about homelessness is his affinity with the other street people. He finds himself welcome on the street but often feels shamed and degraded by conventional society. I have argued for some time that relapse in some people with addictive illness is linked with a pining for social connection. My son might reject housing which restricted his access to his using friends. This is a major problem in abstinence-based housing programs which prohibit any fraternization with persons who use drugs or alcohol.

Sadly, a second leading contributor to harm to the homeless are the social service agencies themselves. It seems that very few of the agencies who assist the homeless in our community are harm reductionist. By that I mean that two of the leading agencies in our town are religiously informed and both approach the problems of the homeless individual more as related to spiritual and moral deficits than clinical issues.  For example, in one program, the staff provides almost no case management, no licensed psychotherapy, no psychiatric care and no assistance with education and vocational training. I hope that this shocks you. Our own son was a resident in one of these agencies and while he remained abstinent from drugs, his mental health problems were not addressed whatsoever.  While living under the auspices of a social service residential program for several months, he was not encouraged to work on his GED or to get a job. Much of his daily time was spent attending prayer meetings.

When I say that the homeless are fatigued by institutionalization, I also mean that they feel devalued and disrespected by those who run the institutions.  It is understandable that day in and day out dealings with the homeless seems to promote a form of authoritarian contempt in those who are overseeing the clients. I fully understand the frustrations of persons working with despairing, angry and even psychotic residents. But that being said, some of the acting out that one sees in the homeless residents is the outcome of a combination of crowding and psychiatric illness. I am told by a former client of one of our local housing programs that the security staff run the shelter more as a prison environment than a shelter. That is, the guards can be bossy and contemptuous of the clients. One homeless woman I know, who recently left a local program, found herself willfully relinquishing a much-needed bed because there were over 92 people bedded down in an 800 square foot room!  It is notable that once COVID-19 hit our town, many of the occupants of this program were routed to cots set six feet apart on the floor of our convention center. Imagine 800 individuals living in close quarters even at the best of times and surely NOT during COVID-19! She acknowledged having periods of uncontrollable weeping because of the stress and drama to which she was subjected on a daily basis. She reported that there was constant background noise of anger, fighting, sadness, irritation and explosiveness all linked to the foolish combination of highly stressed people (many of whom have endogenous mental illness) in very tight quarters. I recall mirroring her by saying that the San Diego Humane Society would never deign to house 50 new dogs in one small room. They would anticipate that the dogs would fight under such stress.

Clearly, every fair-minded American community should embrace a “housing first” philosophy. One cannot complete a GED, apply for a job, attend a job interview showered and in clean clothes, travel to an AA meeting or request entry into a treatment program if one is filthy, freezing cold, angry, confused and emotionally lost. And, by housing, I do not mean placing filthy, cold, angry, confused and emotionally lost individuals on a bunk and believing that one’s job is done. Alas, we have abandoned the homeless and whether you think so or not they are our children and they deserve better.

Caroline Ridout Stewart recently retired from the UCSD Department of Psychiatry where she was a Clinical Instructor and Psychotherapist for over twenty years specializing in the treatment of anxiety and addictive illness. Caroline continues to be a harm reduction provider in her private practice where she enjoys working with those struggling with opioid misuse. She is the mother of a son who suffers from a co-occurring disorder and leads the local NAMI Co-Occurring Support Group for Family Members whose children suffer from both mental and addictive illness. Caroline has been the President of the board of A New PATH (Parents for Addiction Treatment and Healing) for 17 years promoting community Naloxone distribution. She is an artist and essayist.