A Home!

On Thursday, one of my new clients, the very trusting one, moved into her own apartment after 10 years of homelessness. She's young, and she hasn't had a home for all of her adult years. When she heard her move-in was going to happen, she shrieked in happiness. And, importantly, her cats came with her. Well, at least two of the three came with her -- the third is still in the woods at her campsite because she is worried that he won't do well transitioning to indoor living. He's wild, and used to his freedom.

I went to see her on Friday. As I left my office, it started pouring rain. I thought how good it must feel to have a real roof, and not a tent, in such a downpour. 

She met me at the door of her new place. She told me she was worried about one of her cats -- that she thought he was going to die. He had been hiding under blankets since she moved in on the day before, and was crying loudly in the night. So we talked about cats, and how stress affects them. He was under the blanket, but purred when I petted him. I reassured her and told her he looked healthy and that if she gave him a few days, he would adjust. 

As we talked, he started exploring, jumping on the kitchen counter and poking his nose into cabinets. She found these two cats when they were kittens, and ill. She nursed them back to health and they are her family. Her last week in the tent, she fended off a raccoon who had found the cat food and who had been tearing holes in the walls of the tent. She was really ready to come indoors. 

On her first night in the apartment, she slept in a chair on the front porch. Her bed and the couch and floor were full with her community supporters who had joined her for a slumber party. Friday night, she planned to sleep in her bed. After a nice bath.

She said she didn't have food. She opened her refrigerator and we took stock -- she had leftovers from her move-in party, and a couple of frozen pizzas. She said she didn't know how to grocery shop. So we talked about what she'd like to eat, and what she knew how to cook. She made a list, and we went to the grocery store. Milk, butter, eggs, cereal, chicken, hamburger, bread, canned spinach and corn. She'll make spaghetti and hamburgers and baked chicken. 

On days like these, I love my job. 

A whole team in the community helped make this move happen -- young, earnest workers from the Community Empowerment Fund, a group that is working to fight homelessness through strategies to tackle poverty bit by bit (and who came to the apartment for a slumber party on her first night!); Housing for New Hope, a group that works with the homeless and helped with start-up costs; CASA, an agency that provides supportive housing for persons with psychiatric disabilities; Orange Person Chatham Community Operations Center, the program that administers the Shelter Plus Care program that funds housing for the homeless, regardless of income.

There's more to do, and now that she has her apartment, we'll all work with her to help her keep it. 

And we'll figure out what to do with the cat she left behind.

Sorrow

Sometimes my heart breaks. I hear sad stories from my clients frequently, and I can sit with suffering. As a therapist, I know that my ability to be present with a person's pain is a gift, and sometimes my presence is all that I can offer.

The quiet woman is still coming to see me. She is still reluctant to tell me much. This week, she was willing to talk a bit more. In the midst of our session, she handed me a note, addressed to her, and stapled shut. She asked me to open it and read it to her. It was from the social worker at the shelter where she is staying.

The note said that she would need to leave the shelter by June 1. And that she needed to follow the rules, and meet with one of the shelter workers every day at 9:00 a.m.

After I read the note to her, her face crumpled and she started sobbing. Heartwrenching, wracking sobs. She said that people were harrassing her. She said that a few months ago, the director had met with the shelter residents and said, "The people of Chapel Hill hate you, they say they love you, but they hate you." She described feeling humiliated and degraded as the women were following strict rules, and were locked out of their rooms at 8:00 each morning.

I knew that the things she described to me were colored by her paranoia, but there was a truth to them that broke my heart.

Trust Too Little, Trust Too Much?

The quiet woman I wrote about is still coming to see me. When we met last week, she smiled and laughed a couple of times. But she still is very guarded. I can help her with housing, but right now, she won't sign any forms. And there are mountain of forms that go with obtaining housing for a person with a disability. But, she has said that with time, she may be able to tell me more. She saw one of our psychiatrists last week -- when he asked about symptoms, she said she couldn't tell him about them. She clarified and told him "I'm not saying I don't have them." She indicated that she might be able to talk to him in time.

So last week when I saw another homeless woman for an assessment, I got to thinking about trust.

This woman was much younger -- only 28. She has been homeless for 10 years, and for several has been living in a tent with her cats. She has gotten very little in the way of mental health services. She does not have disability benefits, has worked very little, and has no insurance. She described a lifetime of chaos--drug addicted parents, school failure, sexual abuse, head injury, domestic violence, substance abuse. She was very free with what she told me. And she clearly has significant mental health issues, to the point of being disabled. She also came across as smart -- she said she likes to read novels. She told me she has a temper, and even when she wanted to take medicines, she wouldn't remember to. What I see are emotion regulation issues, and problems with executive function -- her ability to plan, organize and make good decisions. She is eager to engage in services to help her find housing, as long as she can bring her cats. She signed a bunch of forms, and we'll start moving along in the process.

This is a woman who was failed by multiple systems for years -- her problems clearly go back to childhood, yet she described no formal services in her early years.

I thought of the contrast in these two women's ability to trust. One who is very slow to trust; and one who may trust too much, too quickly. I'm a trustworthy person, but someone who connects so easily and discloses everything so quickly can be vulnerable out in the world. If we can't trust, we can't connect; if we trust too much, we can be taken advantage of.

But I am hopeful for both of them. They are engaging in services and developing a relationship with me. I hope to use the trust we develop and what I know to help them navigate the system and help them both find homes.

Connection

I met a new client this week. She didn't come to me through the usual route by scheduling an appointment, having her insurance verified, or through referral from the managed care company. She came to see me because someone had told her I would help her find housing. When she came into the clinic asking to see me last week, our clinic administrator was confused--this wasn't the way new clients came in. I spoke to the woman briefly, and asked her to come back to see me at an appointed time, as my schedule was full that day. I wondered if she would come back.

She did come back. We talked on Tuesday. My usual first appointment with a new client is a comprehensive clinical assessment. I have a list of questions, including everything possible about your life, the bad things that have happened, the good, and every possible vice you may have and when you first partook of it. It is the entry point for someone to receive services in the public mental health system.

This woman was too scared to tell me anything. She responded to most of my questions with silence, so I didn't ask many. She told me she didn't have a home. That she lost her apartment in January. And that she has disability benefits. No Medicaid, but she has Medicare (Medicaid is the "golden ticket" for mental health services; Medicare pays very little and many providers simply do not take Medicare patients anymore--too hard to make it work in the business model of behavioral healthcare. Often, someone with Medicare and disability benefits from Social Security had a good work history before becoming disabled, and their disability benefit is too high to qualify for Medicaid.)

The feelings I got from her were of deep sadness and fear. When I asked if she had had mental health treatment, she said she had been in the hospital and was given a diagnosis of schizophrenia and that she used to have a counselor at OPC Mental Health Center (the old community mental health clinic). She had a hospital bracelet on her wrist, and said she had been to the ER for stomach problems recently, but she couldn't remember exactly when. I could read her name and birthdate on the bracelet, but the date of the ER visit had worn off.

I told her it must be difficult not to have a home, and her eyes welled up with tears. I asked her where she was staying now, and she wouldn't tell me. I told her that I didn't have a home for her today, but if she would come and meet with me, I would help her find a home. I told her that being in our clinic usually meant seeing a doctor. She said she would be willing to do that, but indicated she was afraid of medications.

We made our first connection. Will she come back to see me? Will she tell me her story?

Cry for Help

At 5:10, my phone buzzed. Our administrative assistant asked if I could take a call from a mother of a son with schizophrenia. I rolled my eyes, looking at the pile of work on my desk that I needed to get through before I could go home, and said “It’s after five! Stop answering the phone!” But I took the call. The woman on the line sounded like my mom—southern and genteel. Her 50 year old son had schizophrenia, and he wouldn’t let his family in his house. He had shut them all out. He got angry when his family members suggested he needed help, and specifically needed medications. He told them his neighbors were pumping gas into his apartment, and trying to poison him. He was angry and scared, but wouldn’t let his family help him. As she told her story, she started crying, and said “I don’t know what to do. I love my son, and he needs help. I don’t know where to turn.” My eyes welled up, too, feeling guilty about my reluctance to take the call. I swallowed and said “I’ve talked to many families in your situation. You’re not alone. I can help.”

She then told her story—of how her son, though smart and well-educated, always had difficulty holding a job. Seven years ago, he had a psychotic episode. He was hospitalized and treated with medications that were effective. His parents stayed with him in his apartment while he got better, then sold their house in their rural community. They bought a new house in his community, and he lived with them while he recovered. He got a good job, and they continued to support his recovery. About a year ago, he moved into his own apartment.

It’s not uncommon for persons with schizophrenia to stop taking medications. And some may be able to do fine without them. But frequently, psychosis reemerges, and families find themselves at a loss. What to do, how to help?

So we talked, and I went through how to access emergency mental health services. I reviewed the process for an involuntary commitment, with no sugar coating, as this is a terrible thing for a family to have to do, and the response to someone with mental illness is not always humane.  She asked what would happen to her son if she did this – again, no sugar coating, as emergency room waits are long and torturous for someone who is psychotic, and the promise of good treatment once a hospital bed is found is not guaranteed. I gave her phone numbers – the county crisis center, the mobile crisis team, the family support group, NAMI. And I crossed my fingers, hoping that she’d be able to get some help for him, and for her. And in my mind, I knew there had to be a better way, but this is what we have in NC.

I remembered another mother I knew, whose attempts at getting help for her daughter ended up with the daughter in jail for 22 days.  This mom and I spent hours on the phone with jail staff, advocates, mental health workers, hospital staff and anyone else we could think of, trying to get her out of jail and into treatment. She and I both worried that something bad would happen if we didn’t get her daughter out of jail. When I talked with the daughter after the ordeal, she told me how angry she had been at her mother, and how she had told the police officers who responded to the mental health crisis by saying she wanted to go to jail, not to the mental health crisis center. Unfortunately, they honored her request. Fortunately, she and her mother could laugh about the experience.

This is what I do—I listen to stories, I respond with compassion, information and hopefully good advice.  I hope that families will connect with other families through NAMI, and I wish that in all of this, the man who is terrified because of his paranoid delusions will come out of his house, and find some humane response that will allow him to rejoin his family, his work and his community.  It is a simple wish—its granting possible but elusive.

Biology vs. Environment -- ADHD

Good read in the NY Times today: Ritalin Gone Wrong by L. Alan Sroufe

Are stimulant medications helpful to kids diagnosed with ADHD? Seems the evidence is not all that strong.

Our focus on the biology of mental disorders has led to an almost singular focus on pharmaceutical treatment. There's alot of other things that can help.

Day Two: On the Streets and In the Woods

Yesterday we started out slow--second day up at 3:00 a.m. Spencer forgot the gift cards, so we had to meet another team to pick them up. It was cold and clear with a bright starry sky.

First, we decided to drive around the parking lots of shopping centers to see if we could find people who were sleeping in their cars. One of our volunteers had seen a car that she thought someone might be living in near an office complex. She pointed out the car, and I walked over to see if someone was in it. The back windows were open, and I could smell cigarettes and see clothes and bedding. I called out, but got no answer. Spencer looked in the front seat and saw a man asleep under a sleeping bag. He woke up and we asked if he would talk with us. He said no, and asked us to leave him alone. We walked away, but Spencer thought he might know him, so went back and asked again. This time, we got a very clear refusal to participate. We'll note that we found a man sleeping in a car, but that's all the information we'll be able to report.

Next we went back to one of the campsites we visited on Tuesday. This site is by a stream, in town, in a very private area. We found our way, and came into the camp, calling out. We walked through an arch made of bamboo, used the steps cut into the stream bank, and came to a sitting area. Near the chair, there was a small bucket with a toothbrush and toothpaste. The tent was nestled in a spot surrounded by bamboo. I approached, said hello. The man woke up, remembered us from yesterday, and asked that we give him a minute and he would come out talk with us.

He was a Hispanic man, in his mid-40s, dressed in casual clothes. He said he used to live in an apartment in Carrboro but couldn't pay for it and had to leave. He was the only one in the camp that night, but said that others come and go, and some get "bad drunk." He was willing to do the survey, and gave us his name and social security number, and let us take his photo. He works when he can, doing odd jobs.

He told us he had a heart condition, and showed us a device strapped to his chest. He gets his treatment at UNC in cardiology. He didn't know the name of his condition, but said he loses consciousness about once  every 40 days, and that the device gives him a shock. Was it a defibrillator?

One of the purposes of the Vulnerability Index is to identify those homeless individuals most at risk of death. We had just found one. There were no signs of severe mental illness, perhaps some anxiety and sadness, but what would you expect when you aroused in the middle of the night by a group of strangers?

He told us there were other campsites nearby, and gestured and pointed. We tried to find the another site, but couldn't find a path, and found our way blocked by a fence.

From there, we went back to the sites we had seen on Tuesday, close to I40. We walked into the woods, and found the tent empty, just as it had been the day before. Spencer wanted to walk further into the woods so we started walking and saw a light ahead of us. That led us to a second tent, and a man wearing a headlamp. Spencer knew him.

He was white, in his mid-40s. He said he had been homeless for more than year, and had had to leave the shelter when we started a work program. He goes to the program daily. He had recently been denied disability but was planning on appealing. He was skinny, with a cup of coffee in his hand, and shivered in the cold. He had been in foster care. Had had a head injury. And he had recently been diagnosed as having the early stages of mesothelioma. He was nicely dressed, and said that he slept in the tent, and then caught the bus into down and tried to stay busy in the day. One of the volunteers asked if he panhandled, and he said he would never do that.

He pointed out a tent a short distance away--the occupant had already left for the day.

The site I would have liked to have seen in Chapel Hill was also near a stream near a bridge. There was a man who lived there who was an artist -- he built mosaics around the camp, and brought in calla lilies and other plants to beautify the area. We had heard that the artist was no longer there, having decided to return to his homeland.

The image below is not from one of our camps -- but it gives you an idea of the care some people put into making these spaces a home.

In contrast, other sites looked like this:

http://www.aksenate.org/ellis/121109_homeless_camp.jpg

We had a great team, and talked about meeting to continue our early morning walks in the woods. It was heartwarming to see the volunteer participation in this event--some of us mental health workers and community activists and others concerned and caring citizens. I learned alot, and will have more to say on the experiences.

Watch for an article on the initiative in this Sundays' News and Observer.