We’ve all seen it. That person at the intersection screaming wildly at passing cars, sometimes obstructing traffic. Dilated pupils marred with fear and confusion. We respond with our own fear, perhaps pity, and continue with our daily routines, hoping and praying that the individual will somehow “access services” and get the help they need. Intentional or not, we fail to recognize that this individual’s very existence is evidence that the solution is not so ‘cut and dry.’ We need more robust intervention methods that humanize the homeless and acknowledge the co-occurring mental health disorders that accompany homelessness.
One of the sad realities of chemically-induced psychosis is the vivid recollection of traumatic events despite the sober mind’s ability to reinterpret them with a modicum of clarity. I remember it all like it was yesterday. Former truths have, since then, morphed into fiction but the fear was real. Years earlier, when I worked with child-centered community development projects in the Middle East, one common refrain from providers was the existence of traumatic stress disorder, the concept of “post” being unrealistic in war-torn refugee camps.
No one escapes refugee camps, or homelessness, without a mental health diagnosis. Homelessness is a deeply traumatic and mind-altering experience even without the drugs. We need to acknowledge that. I was lucky to escape the streets of Portland with only PTSD and substance use disorders in tow. Others are less fortunate. They are sick, and they need our help. Before we continue, let’s reinforce the need to dispel a common myth. Homelessness isn’t a choice. It is the result of systemic individualism and the lack of social supports.
Survival vs. living
Mental health crises are episodic and the people experiencing them still are, and behave like, people. Moreover, they are expected to behave like people. An individual experiencing chemically-induced psychosis also contends with the immense amount of time and setbacks it takes to get off the street.
Days spent packing up and storing belongings only to stand in long lines at DHS, social security, the DMV, and walk-in mental health clinics are lost when cell phones and ID’s are stolen and/or confiscated. An endless cycle emerges where losing a backpack can amount to about a month’s worth of work. This places an enormous burden on the individual to be sane enough to get the help they need. It's not impossible, I did it, others have done it. But for every single homeless individual experiencing co-occurring conditions, success is highly improbable.
We must be careful not to conflate survival with the luxury of living. What does it mean to survive? Food, water, shelter, were my requirements, and the vehicle to obtain them was community. Community? Yes, community. Survival, at least for me, meant working with others.
Community and survival
A 48-hour rule on reclaiming abandoned property, the idea that no one had the right to tell anyone to move their tent, village elders to arbitrate disputes, these were all very real occurrences. All crimes (save heinous ones) were forgiven and central to that ethos was the belief that passing judgement on each other based on infractions to laws created by a society that had abandoned us contradicted the biological imperative to survive.
It wasn’t like this everywhere. In some places, it was simply anarchy. But in larger, established encampments, the trappings of social order began to emerge as they do everywhere else on Earth. So why is this relevant? When we sweep encampments, we uproot these fledgling communities without building better ones. Fortunately, there is an inherently positive and prolific solution.
The power of recovery
Anyone who works in, or has participated in “recovery,” an umbrella term for 12-step and similar programs of recovery, understands that community building and developing positive interpersonal relationships has immense therapeutic value. People desire to belong to something greater than themselves, and this phenomenon can be leveraged to help people rebuild their lives. The rooms of recovery are full of stories of people being met at inflection points who were stable enough, in that moment, that they decided to do something different. Recovery, at least in Portland, is a bona fide social movement and a lifesaving one for many. But for those in psychosis with co-occurring disorders, outside help is needed.
One excellent solution is stabilization and readiness programs that prepare individuals to access treatment and recovery of their own volition. These kinds of programs — that do not have a sobriety requirement for housing but do require some form of engagement in exploring options for treatment — are well designed but underfunded. But a major problem remains. We, as a society, have for too long imagined treatment, psychiatric hospitals, jail, stabilization programs and other institutions as the point of entry. This is inaccurate.
Reimagining the sidewalk as an emergency room
We cannot anticipate when people will be ready to make changes in their lives, but we must be ready when they are. The sidewalk is the point of entry and like hospitals, sidewalks must become well equipped to treat myriad disorders. That means they must become well-staffed with trained experts and providers. Outreach workers from all agencies, be they government or NGO, should at a bare minimum be licensed Qualified Mental Health Professionals or at least Qualified Mental Health Associates by the Mental Health and Addiction Certification Board of Oregon.
These credentials should be offered by agencies as part of their career development for everyone being hired to do outreach work and their salaries should reflect that expertise when training is completed. Credentialing should occur on the job and outreach workers, with lived experience, could be a pathway to solving the behavioral health crisis in this state from the ground up.
What will this accomplish? A cadre of first responders who are equipped to treat the condition of psychosis and deescalate risky situations. But then what? That’s the big question. Once a “patient” is deescalated, we cannot repeat the cycle of abandonment. We need immediate solutions to housing, detox and behavioral health treatment for anyone who is willing to go.
Toward a comprehensive solution
Immediate referrals aren’t a “nice to have,” they are “a must have.” When someone says, “I’m an addict, I need help,” or, “I don’t want to be homeless anymore,” this is a moment of clarity. These moments are rare and every police officer, EMT, peer support and outreach worker that hears these words needs to be empowered with the ability to say, “OK, lets go.” This also means more walk-in clinics and zero wait times for detox, treatment and stabilization centers and an established and speedy pathway to permanent housing. Nothing less will work.
In addition, no one exiting incarceration should ever, ever be released to the sidewalk for any reason. Parole transition should be a requirement for every inmate released. There is a ton of anecdotal evidence that the incentive to avoid incarceration by entering treatment has led to an awakening. Our legal system ought to order recovery and treatment over incarceration if Measure 110 is amended.
Shelter beds while perhaps logistically necessary for a few days also do not work. Dormitories do not work as permanent solutions. I cannot overestimate that therapeutic value of the peace of mind that comes with knowing that one’s property will not be lost or stolen, and that when you close your eyes, you have better than a 50/50 chance of waking up.
Sanitation is a human right
Have you ever used the Portland Loo? If these sites are operational, they are chronically overused and toxic. Port-o-potties are a temporary solution. Water fountains (although they kept me alive and for that I am grateful) are equally polluted. We’ve already established that one cannot be homeless without being traumatized. Expecting the mentally ill and intoxicated to make positive life choices without a safe place to use the bathroom or take a shower, never mind fear of being stabbed, robbed or raped in their sleep, imposes an unreasonable expectation on the human mind.
Yes, it’s an expensive proposition but having trained professionals that can deescalate those in crisis with immediate relocation pathways to places where real healing can occur is the only way to solve this problem. Understanding this means overcoming the culture of contempt for the homeless, for how they got there, for how they behave themselves, and for their inability to overcome the immense challenges in the name of improving the aesthetic of our city streets. The truth is they shouldn’t have to.
We need to be willing to meet basic human needs and human rights at the point of contact before recovery is even possible. Nobody should be given a tent and sent on their way. We can do better.
Jonathan Mroz is a former educator, policy and research fellow who has published on counter-radicalization methodology. Formerly unhoused, Mr. Mroz currently resides in Portland, Oregon. Mr. Mroz is a Certified Recovery Mentor through MHACBO with lived experience and is employed by Central City Concern. His views are personal and do not necessarily reflect the views of Central City Concern or its affiliates.