Humble Abode: Recovery starts at home?if you have one
Schizophrenia Magazine
By Michelle Morra
When Los Angeles Times columnist Steve Lopez asked a homeless street musician if he would consider sleeping indoors, the man said, ?Oh, no. I wouldn?t want to do that.? This puzzling response is the premise of The Soloist, a movie based on Lopez? newspaper and book accounts of that homeless man, Nathaniel Ayers.
Ayers (played by Jamie Foxx) was a gifted cellist studying at Julliard when symptoms of schizophrenia forced him to halt his studies. Years later he met Lopez (played by Robert Downey Jr.), a journalist who was stuck for a good story and wanted to know how a man like Ayers ends up living on the street.
Ayers lived on the streets of Los Angeles, and he was loved. His sister, while out of touch, missed him terribly and was heartbroken at the thought of him not having a safe place to live.
Dale L. Johnson, PhD, of Houston knows what it?s like. His son, Jay, had schizophrenia and frequently ended up lost or homeless. Sometimes, Johnson and his wife received calls from a police officer who had jailed him to keep him warm for the night. Jay, who had dropped out of Harvard when his illness progressed, escaped from state hospitals. He hitchhiked, slept on the streets, and was often beaten and robbed. This would force him to panhandle for more funds, and the cycle would repeat itself.
Finally, the Johnsons learned of a low-income housing and support facility run by Volunteers of America, which had a vacancy. Once Jay had a home of his own, things started to fall into place. Doctors found him a drug that worked without harsh side effects. He had a roommate he liked. Rather than scrambling for the next meal or hiding place, life became a more stable routine of visiting the library, going to the gym, having coffee at Starbucks, and taking the trolley to the ocean.
Things don?t fall into place for people who are homeless, regardless of their mental state. The prognosis is bad. Death rates are high, rape and violence higher.
Sadly, the Johnsons? son died four years ago of natural causes unrelated to his mental illness. But the home he enjoyed in his final years was a blessing to him and to his parents, who visited him in the San Diego area many times.
Not all accommodations are so pleasant. People with schizophrenia commonly endure living conditions in community-assisted housing of varying degrees of sanitation, comfort, and safety. The prospect of spending one?s adult life in such a place, with little to no personal privacy, can be especially uninviting. But while many leave those homes in hopes of a better life on the street, Johnson believes that is the wrong choice.
?Any group home is better than homelessness,? he says. ?Any. And some are just dreadful.?
Still, carving out one?s own existence in some quiet tunnel or under a tree might seem more appealing than relying on the system. Someone like Ayers who is mistrustful of strangers will, understandably, want to be alone. But how long can a person with schizophrenia sustain a life on the street, without access to treatment, privacy and safety? And if a shelter were of questionable help in a person?s recovery from mental health, would the prognosis be better in a permanent residence?
Gimme shelter
For a gentle soul like Nathaniel Ayers, the street is not always the worst demon. There?s a disturbing scene in The Soloist where Ayers, in a flashback to his Julliard days, is beaming with pride in his beautiful new apartment. But he is soon distracted by a voice, then two or three voices, then a barrage of voices, shouting confusing messages all at once in his head. A happy moment turns to anguish as he is reduced to sobbing on his kitchen floor.
We all have voices in our heads: contemplations, reflections, ideas―although not the audible voices many with schizophrenia hear. When we see a homeless person, our voices might say, ?Why doesn?t he just get a job?? or ?Don?t my taxes pay for assisted living?? or ?If she chooses to sleep there of all places, that?s her problem, not mine.?
The Soloist explores a complex question: Why would Ayers, or anyone who is afraid, paranoid, and vulnerable, not gravitate to the nearest shelter or try harder to find a permanent home? To the frustration of the well-meaning Lopez, initial attempts to house Ayers fail.
In fairness to Ayers, the local shelter with its long lines of crack addicts, pushers, and other jittery, restless and violent characters, certainly does not seem like a step up from the quiet nook where he sleeps on a tarp next to his shopping cart. But when Lopez finds him a room of his own, to use both as a music studio and as a permanent home, Ayers rejects it, responding with aggression: ?I don?t want to live here?I don?t want to die in here?I want to be in the tunnel and hear the city sounds?I don?t belong here. I?m never coming here again.?
At Lopez? suggestion that Ayers ?should? live there, Ayers becomes extremely agitated, triggered by the ?s? word that threatens his independence.
Independence may be the key to ?housing first,? a type of intervention that is gaining momentum in recent years. In 1992, Sam Tsemberis, PhD, founded Pathways to Housing, Inc. in New York City as he found the previous system sorely lacking. He had been director of a program called the Homeless Emergency Liaison Project (HELP), launched in the 1980s, where his job was to identify the mentally ill homeless people whose health and safety were in jeopardy, and take them to the psychiatric center at Bellevue hospital―whether or not they wanted to go.
?It was not about consumer choice,? he recalls. ?It was very intense, clinically driven, and very traumatic for all of us. There was disagreement among the teams about whether we were really helping anybody.?
After such an intense process, he says, only one or two of the 30 hungry, exhausted people he saw each day were admitted to hospital. And even those who made it to Bellevue for medical care and a few good meals were back on the street 30 days later, with no follow-up.
Tsemberis felt there was something broken in that system. ?We always saw the same people on the streets,? he says, ?and they made a compelling case that they needed housing above all.?
In some cases, people find themselves stepping up through the system?s shelters, group homes, boarding homes, and other accommodations before being given the option of a permanent dwelling. Once that opportunity arises, the person must meet certain conditions, such as agreeing to attend weekly group therapy sessions, quit drinking, or take medication.
For those suffering from severe mental illness, that ?treatment first? system presents a host of barriers. Housing becomes about what form to fill out, what doctor to see, what diagnosis the person has, what medications were prescribed. Many homeless people are too preoccupied with staying safe or getting their next meal to abide by rigid schedules or show up to meetings on time. Many still do make their way through this system with varying degrees of success. Others wait years for an opportunity to apply for a permanent home; many fall through the cracks.
After many failed attempts at housing those in need, Tsemberis started paying attention to what homeless individuals really wanted. Many said they didn?t want facilities with tiny rooms and groups of social workers in the basements. They wanted the freedom to have guests, or pets, and choose what meals to cook, what TV channels to watch. ?They had a life before, and they wanted some restoration of that life.?
?Housing first? is based on the premise that housing is a basic human right, not a reward for clinical or programmatic success. When staff find someone living under a bridge or on the sidewalk, they ask, ?How can we help you find housing?? If the person is ready to talk, staff get to know the person?s situation and identify what type of funding he or she is eligible for under disability or social assistance benefits. Then, together, they find a dwelling.
Once housed, the person receives regular visits from a mental health professional who helps set personal goals―such as seeking treatment, or opening a bank account―but imposes no requirements.
People respond well to this approach, and being actively involved might be a key factor. They have a say in where they live. They also choose their own furniture and d?cor from a furniture bank and get to decide where everything goes.
Toronto City Council founded a similar project in 2005. ?Streets to Homes? was Canada?s first housing model of its kind and several other municipalities have adopted similar programs. New York City has seen a consistent rate of 80 percent of people staying housed through Pathways to Housing. In Toronto, nearly 92 percent stay housed, and 83 percent are still in the original dwelling they chose.
One unique aspect of the housing first model is that if things go wrong, people can try again. That?s a welcome change from the alternative system, where a breach of the rules could land them back to the streets indefinitely.
?Some may not make great choices the first go-around,? says Iain De Jong, Manager of Streets to Homes. ?We need to look at homelessness from a recovery lens and acknowledge that relapse is part of recovery. Some relapse into homelessness.?
Tsemberis agrees with giving people another chance until they get it right. To anyone who might find this too lenient an approach, he says, ?It?s just like when rich people go to the Betty Ford clinic. They don?t lose their house just because they?ve relapsed.?
Depending on the severity of their illness, some might choose a living arrangement with 24-hour access to care, but many live very well independently.
Either way, Tsemberis believes there is little chance for a positive outcome without a home.
?People recover more quickly from mental illness than they do from poverty,? he says.
Be it ever so humble?
There?s no place like home. But here come those voices again:
?What if someone with schizophrenia was alone at home and forgot to turn off the stove?? ?Would that be fair to other building occupants?? ?Is a person with schizophrenia safe on a balcony??
?With kitchen utensils?? ?Will he not harm himself or others if left to his own devices??
Tsemberis once had those same apprehensions. Today, he believes that his entire profession has been wrong about what people diagnosed with schizophrenia are able to do.
?We have focused so much on their disabilities, their symptoms, and on classifying them,? he says, ?we have missed the fact that many are so capable, they can be homeless and on the street and manage to survive.?
He no longer wonders if people with mental illness can manage apartments on their own. He has seen their skills in action.
?They know when soup lines are serving food, where to sleep, who they can trust, where to go to the bathroom, how not to get arrested. Just by virtue of their survival on the street, there?s so much they can figure out for themselves. Then, to take someone with all this capability into an apartment? To them, it?s a piece of cake.?
It takes a certain degree of trust to grant someone independence. Remarkably, though, that independence can bring great results for the mentally ill.
Johnson calls independence ?one of the essentials of recovery.? It certainly worked for his son, and he has seen countless examples of how well people can live with mental illness when given the dignity of choice and freedom. He cites as an example Magnificat House, Inc., a supported apartment program where he has worked as a volunteer consultant for 40 years. Founded in 1968 in Houston, it runs nine residential houses and provides immediate and direct aid to anyone who needs a place to live, with few questions asked. About one-third of residents have a serious mental illness.
?It?s in the middle of Houston and no one knows it?s there,? says Johnson. ?The residents do all the work. If a toilet is stopped up or the roof leaks, they fix it. They mow the lawns, trim the hedges; have a big garden that produces enough vegetables to feed all the residents and have some left over for the Farmer?s Market.? Johnson says it?s a place where people want to live, for many years―and many of them do.
What about people like Nathaniel Ayers, who at some point make a conscious decision to live on the street? His decision, like the decisions of many, was likely the result of an untreated brain disease. He may have needed coaxing but once he got used to his permanent home, he stayed.
?His mental health is as precarious as before,? says Lopez at the end of the film. Only now he has a bed. A safe place to keep his cello. Dignity. And a friend in Steve Lopez. Ayers still lives in Los Angeles, where he plays several musical instruments.
?Housing is a powerful motivator,? says Tsemberis. ?For some people, this is the first time they?ve had an apartment of their own. They have lived with family, in foster care, in jail or in shelters?but a home of their own gives them a sense of dignity and pride. People care about it and want to get their act together. It?s really quite beautiful to observe all of that transformation.? e
Michelle Morra is a freelance journalist, corporate writer, and aspiring novelist who works from her home in Toronto, Ontario.
Schizophrenia Magazine
By Michelle Morra
When Los Angeles Times columnist Steve Lopez asked a homeless street musician if he would consider sleeping indoors, the man said, ?Oh, no. I wouldn?t want to do that.? This puzzling response is the premise of The Soloist, a movie based on Lopez? newspaper and book accounts of that homeless man, Nathaniel Ayers.
Ayers (played by Jamie Foxx) was a gifted cellist studying at Julliard when symptoms of schizophrenia forced him to halt his studies. Years later he met Lopez (played by Robert Downey Jr.), a journalist who was stuck for a good story and wanted to know how a man like Ayers ends up living on the street.
Ayers lived on the streets of Los Angeles, and he was loved. His sister, while out of touch, missed him terribly and was heartbroken at the thought of him not having a safe place to live.
Dale L. Johnson, PhD, of Houston knows what it?s like. His son, Jay, had schizophrenia and frequently ended up lost or homeless. Sometimes, Johnson and his wife received calls from a police officer who had jailed him to keep him warm for the night. Jay, who had dropped out of Harvard when his illness progressed, escaped from state hospitals. He hitchhiked, slept on the streets, and was often beaten and robbed. This would force him to panhandle for more funds, and the cycle would repeat itself.
Finally, the Johnsons learned of a low-income housing and support facility run by Volunteers of America, which had a vacancy. Once Jay had a home of his own, things started to fall into place. Doctors found him a drug that worked without harsh side effects. He had a roommate he liked. Rather than scrambling for the next meal or hiding place, life became a more stable routine of visiting the library, going to the gym, having coffee at Starbucks, and taking the trolley to the ocean.
Things don?t fall into place for people who are homeless, regardless of their mental state. The prognosis is bad. Death rates are high, rape and violence higher.
Sadly, the Johnsons? son died four years ago of natural causes unrelated to his mental illness. But the home he enjoyed in his final years was a blessing to him and to his parents, who visited him in the San Diego area many times.
Not all accommodations are so pleasant. People with schizophrenia commonly endure living conditions in community-assisted housing of varying degrees of sanitation, comfort, and safety. The prospect of spending one?s adult life in such a place, with little to no personal privacy, can be especially uninviting. But while many leave those homes in hopes of a better life on the street, Johnson believes that is the wrong choice.
?Any group home is better than homelessness,? he says. ?Any. And some are just dreadful.?
Still, carving out one?s own existence in some quiet tunnel or under a tree might seem more appealing than relying on the system. Someone like Ayers who is mistrustful of strangers will, understandably, want to be alone. But how long can a person with schizophrenia sustain a life on the street, without access to treatment, privacy and safety? And if a shelter were of questionable help in a person?s recovery from mental health, would the prognosis be better in a permanent residence?
Gimme shelter
For a gentle soul like Nathaniel Ayers, the street is not always the worst demon. There?s a disturbing scene in The Soloist where Ayers, in a flashback to his Julliard days, is beaming with pride in his beautiful new apartment. But he is soon distracted by a voice, then two or three voices, then a barrage of voices, shouting confusing messages all at once in his head. A happy moment turns to anguish as he is reduced to sobbing on his kitchen floor.
We all have voices in our heads: contemplations, reflections, ideas―although not the audible voices many with schizophrenia hear. When we see a homeless person, our voices might say, ?Why doesn?t he just get a job?? or ?Don?t my taxes pay for assisted living?? or ?If she chooses to sleep there of all places, that?s her problem, not mine.?
The Soloist explores a complex question: Why would Ayers, or anyone who is afraid, paranoid, and vulnerable, not gravitate to the nearest shelter or try harder to find a permanent home? To the frustration of the well-meaning Lopez, initial attempts to house Ayers fail.
In fairness to Ayers, the local shelter with its long lines of crack addicts, pushers, and other jittery, restless and violent characters, certainly does not seem like a step up from the quiet nook where he sleeps on a tarp next to his shopping cart. But when Lopez finds him a room of his own, to use both as a music studio and as a permanent home, Ayers rejects it, responding with aggression: ?I don?t want to live here?I don?t want to die in here?I want to be in the tunnel and hear the city sounds?I don?t belong here. I?m never coming here again.?
At Lopez? suggestion that Ayers ?should? live there, Ayers becomes extremely agitated, triggered by the ?s? word that threatens his independence.
Independence may be the key to ?housing first,? a type of intervention that is gaining momentum in recent years. In 1992, Sam Tsemberis, PhD, founded Pathways to Housing, Inc. in New York City as he found the previous system sorely lacking. He had been director of a program called the Homeless Emergency Liaison Project (HELP), launched in the 1980s, where his job was to identify the mentally ill homeless people whose health and safety were in jeopardy, and take them to the psychiatric center at Bellevue hospital―whether or not they wanted to go.
?It was not about consumer choice,? he recalls. ?It was very intense, clinically driven, and very traumatic for all of us. There was disagreement among the teams about whether we were really helping anybody.?
After such an intense process, he says, only one or two of the 30 hungry, exhausted people he saw each day were admitted to hospital. And even those who made it to Bellevue for medical care and a few good meals were back on the street 30 days later, with no follow-up.
Tsemberis felt there was something broken in that system. ?We always saw the same people on the streets,? he says, ?and they made a compelling case that they needed housing above all.?
In some cases, people find themselves stepping up through the system?s shelters, group homes, boarding homes, and other accommodations before being given the option of a permanent dwelling. Once that opportunity arises, the person must meet certain conditions, such as agreeing to attend weekly group therapy sessions, quit drinking, or take medication.
For those suffering from severe mental illness, that ?treatment first? system presents a host of barriers. Housing becomes about what form to fill out, what doctor to see, what diagnosis the person has, what medications were prescribed. Many homeless people are too preoccupied with staying safe or getting their next meal to abide by rigid schedules or show up to meetings on time. Many still do make their way through this system with varying degrees of success. Others wait years for an opportunity to apply for a permanent home; many fall through the cracks.
After many failed attempts at housing those in need, Tsemberis started paying attention to what homeless individuals really wanted. Many said they didn?t want facilities with tiny rooms and groups of social workers in the basements. They wanted the freedom to have guests, or pets, and choose what meals to cook, what TV channels to watch. ?They had a life before, and they wanted some restoration of that life.?
?Housing first? is based on the premise that housing is a basic human right, not a reward for clinical or programmatic success. When staff find someone living under a bridge or on the sidewalk, they ask, ?How can we help you find housing?? If the person is ready to talk, staff get to know the person?s situation and identify what type of funding he or she is eligible for under disability or social assistance benefits. Then, together, they find a dwelling.
Once housed, the person receives regular visits from a mental health professional who helps set personal goals―such as seeking treatment, or opening a bank account―but imposes no requirements.
People respond well to this approach, and being actively involved might be a key factor. They have a say in where they live. They also choose their own furniture and d?cor from a furniture bank and get to decide where everything goes.
Toronto City Council founded a similar project in 2005. ?Streets to Homes? was Canada?s first housing model of its kind and several other municipalities have adopted similar programs. New York City has seen a consistent rate of 80 percent of people staying housed through Pathways to Housing. In Toronto, nearly 92 percent stay housed, and 83 percent are still in the original dwelling they chose.
One unique aspect of the housing first model is that if things go wrong, people can try again. That?s a welcome change from the alternative system, where a breach of the rules could land them back to the streets indefinitely.
?Some may not make great choices the first go-around,? says Iain De Jong, Manager of Streets to Homes. ?We need to look at homelessness from a recovery lens and acknowledge that relapse is part of recovery. Some relapse into homelessness.?
Tsemberis agrees with giving people another chance until they get it right. To anyone who might find this too lenient an approach, he says, ?It?s just like when rich people go to the Betty Ford clinic. They don?t lose their house just because they?ve relapsed.?
Depending on the severity of their illness, some might choose a living arrangement with 24-hour access to care, but many live very well independently.
Either way, Tsemberis believes there is little chance for a positive outcome without a home.
?People recover more quickly from mental illness than they do from poverty,? he says.
Be it ever so humble?
There?s no place like home. But here come those voices again:
?What if someone with schizophrenia was alone at home and forgot to turn off the stove?? ?Would that be fair to other building occupants?? ?Is a person with schizophrenia safe on a balcony??
?With kitchen utensils?? ?Will he not harm himself or others if left to his own devices??
Tsemberis once had those same apprehensions. Today, he believes that his entire profession has been wrong about what people diagnosed with schizophrenia are able to do.
?We have focused so much on their disabilities, their symptoms, and on classifying them,? he says, ?we have missed the fact that many are so capable, they can be homeless and on the street and manage to survive.?
He no longer wonders if people with mental illness can manage apartments on their own. He has seen their skills in action.
?They know when soup lines are serving food, where to sleep, who they can trust, where to go to the bathroom, how not to get arrested. Just by virtue of their survival on the street, there?s so much they can figure out for themselves. Then, to take someone with all this capability into an apartment? To them, it?s a piece of cake.?
It takes a certain degree of trust to grant someone independence. Remarkably, though, that independence can bring great results for the mentally ill.
Johnson calls independence ?one of the essentials of recovery.? It certainly worked for his son, and he has seen countless examples of how well people can live with mental illness when given the dignity of choice and freedom. He cites as an example Magnificat House, Inc., a supported apartment program where he has worked as a volunteer consultant for 40 years. Founded in 1968 in Houston, it runs nine residential houses and provides immediate and direct aid to anyone who needs a place to live, with few questions asked. About one-third of residents have a serious mental illness.
?It?s in the middle of Houston and no one knows it?s there,? says Johnson. ?The residents do all the work. If a toilet is stopped up or the roof leaks, they fix it. They mow the lawns, trim the hedges; have a big garden that produces enough vegetables to feed all the residents and have some left over for the Farmer?s Market.? Johnson says it?s a place where people want to live, for many years―and many of them do.
What about people like Nathaniel Ayers, who at some point make a conscious decision to live on the street? His decision, like the decisions of many, was likely the result of an untreated brain disease. He may have needed coaxing but once he got used to his permanent home, he stayed.
?His mental health is as precarious as before,? says Lopez at the end of the film. Only now he has a bed. A safe place to keep his cello. Dignity. And a friend in Steve Lopez. Ayers still lives in Los Angeles, where he plays several musical instruments.
?Housing is a powerful motivator,? says Tsemberis. ?For some people, this is the first time they?ve had an apartment of their own. They have lived with family, in foster care, in jail or in shelters?but a home of their own gives them a sense of dignity and pride. People care about it and want to get their act together. It?s really quite beautiful to observe all of that transformation.? e
Michelle Morra is a freelance journalist, corporate writer, and aspiring novelist who works from her home in Toronto, Ontario.
