The stories that appear below are:

  • The end of my mother’s life: there must be a better way – by Dr. Lloyd Sederer
  • A mental health recovery story about Patricia Deegan, PhD, as told by Dr. Lloyd Sederer
  • What does it take to get something done? by Dr. Lloyd Sederer

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The end of my mother’s life: there must be a better way

My mother died on a Monday not long ago. We buried her, in the Jewish tradition, the next day. But we lost her over a year before when a cardiac event she survived robbed her brain of the oxygen that sustains it and ushered in a dementia that took her away well in advance of her death.

She was ninety and I try to recall the long and full life she lived. But the erosion of her later years, especially when she lived in the fog and psychic distress that a compromised brain induce, occupy the foreground of my mind.

Dementia is a cruel disease – whether delivered by Alzheimer’s, or stroke and other circulatory problems. Memory loss is just the surface of it all, and more germane to the person affected early on when they know they are losing it. But when more advanced, dementia destroys our sense of time and location and the mind becomes awash in eras, places and people past. For my mother it was her years as a young woman in New York City and the family I recall as a child. Had her mind conjured up sweet memories maybe we all would welcome an escape to times long ago. But no, she was frequently helpless and unable to find someone or do something that to her had a sense of urgency. When will Abe be here to get me? I’m not ready, let’s get going! Where is Eva? These reveries would escalate in intensity as would the volume of her crying out. I have seen this state in many people with dementia.

The mental torment of dementia is what gives it its unique cruelty. There is no way the sufferer can say, ‘here is where and how it hurts’. They suffer and seek relief with actions that do not serve them or simply know not what to do. Mental pain, helplessness and no exit are the trinity that drive suicide in the cognizant; for those whose minds cannot process what is happening their distress mounts, which we see in their agitation, moans and screams. As horrific as is the psychic pain of dementia, I wonder if it gets the recognition it warrants. Medical care has come to appreciate the crucial importance of mitigating physical pain but mental pain, no less agonizing, has yet to receive its proper due. Psychic pain is as distressing as physical and to make things worse, for dementia it has few good remedies.

I know death was a relief for my mother, a desired end. She told me so, echoing earlier conversations, last year before her brain was so damaged and when she had the clarity to see her debility growing. She also had made her wishes perfectly clear years before in her health care proxy and power of attorney. She understood, though never used the term, what ‘dying with dignity’ meant. She also did not want to be a burden to the family; even when she barely could think she always answered a question I would ask about her with a return question that asked about me. “Are you hungry? Where will you sleep tonight? Was it a long drive to get here?” Even when she did not recognize who I was.

While my mother saw her debility coming and she was already wheelchair bound, she could not foresee, nor could we her family, that overnight she would go from frail and slowly mentally failing to severely demented. Six years earlier she had moved from her own home, long a widow, into what we call a retirement community – one where as age and infirmity mount a person moves to greater levels of support and care, with the highest level being a skilled nursing facility. And that was where she spent the last year of her life among two dozen others on a ward devoted to those with dementia.

Her residence was one that money could buy. She and we received thoughtful, kindly and capable services. Kindly was perhaps what helped her the most during the dog days of confusion and fearfulness. I don’t like to think of the countless others who will never receive this standard of care.

As a doctor, I have seen death. But up close and personal as it was with my mother over a protracted time (my father died in weeks from the complications of a cancer) I was taught anew how death is usually a process. Only the very final stage – when breathing, pulse and blood pressure signal that life is unsustainable – has a pretty predictable clock of hours to days, at most. Otherwise, dying marches to its own drummer. Never believe what you are told even by the most august of experts because dying follows the law of large numbers, which is to say there is very great variance around an average (known as a distribution curve) and for all those who fall into the average time predicted many proceed more quickly and many more slowly into the good night. I made a few trips this past year prepared for a funeral only to return home having discovered that it was not quite time.

Which is also to say that decisions abound during the process of first declining then dying. Not to mention the often tortuous decisions about money, there are decisions about treatments: how should someone be treated for their illness as well as the cascade of complications that frequently befall someone as their immunity diminishes and their infirmity increases. There are decisions about care taking: home or institution, supplementing or not the staff of a facility or the family at home. There is the decision about whether to hospitalize during a crisis and then what is done at the hospital; the most well known decision is whether to ‘DNR’ (Do Not Resuscitate) but the questions are far more nuanced, as a rule. Here is where a living will or health care proxy is a blessing; no need to guess about someone’s wishes, because you know mostly about whether to use aggressive measures like a breathing tube and ventilator, or about using antibiotics, or food given through a tube or into the veins when someone cannot nourish themselves. When aversion to death results in no prior talks or clear wishes we have added perplexity and potential family conflict to the already heartbreaking process underway.

Whose responsibility is it anyway to talk about and decide the tough and chilling choices for the process of the near to and end of life? Of course that will differ with each person and family. But what seems the most troubling is when each party looks to another instead of joining with each other -  including the person whose life it is, their families and other loved ones, and medical professionals charged with their care – to face the process of clarifying, recording and bearing the emotional demands this evokes. My family is big on reality, facing it unblinking, so we were fortunate to know the road we needed to follow. Be kind and deal with the process of decision-making as early as possible. That will be a gift to all concerned.

Just as we know from the bible and its popularization there is a time to live and a time to die. My mother’s time was ushered in after she fractured her hip trying to climb out of bed during a night of terror we could only infer from her distress. But here is a story about American medicine that seems to need telling.

The fracture was discovered some days after it occurred when she was rushed to the hospital with trouble breathing. I received a call from the physician’s assistant to the chief of orthopedic surgery. My mom had a hip fracture but the bone had not been displaced from its socket. There was no way to have known since she had not walked for more than two years and relied on a wheelchair for mobility. She was in no pain. The PA said they wanted to operate, to place a set of screws in her hip. When I said I would speak with my family but I thought not that was when I found out how ill programmed our health care system is, so to speak. I called back to say no and soon received a call from the surgeon himself to urge me to proceed with the surgery. I can’t imagine what someone not a doctor might do. I had learned that the standard of care in Europe for such a fracture in someone as infirm and incapacitated was 3-4 weeks of bed rest. I knew my mother was failing and she had no pain. Why would we subject her to surgery that would cause great pain, from which she would possibly not survive or if she did infection could readily follow, and would debilitate her even further in the remaining days of her life? What if my family had to pay, instead of pretending we did not because Medicare would when, in fact, we are all paying for Medicare and an alarming percentage is on late life treatment that does little or nothing of benefit? So we held our ground, no surgery happened and off to bed rest my mother went after she left the hospital and returned to the nursing home.

That moment was a wake up call for our family. We asked ourselves what would give mom the best moments of life and experience in the time she had left? We realized that goal would be best achieved if we placed her in hospice care. This may sound oxymoronic but when the time comes give it a try. Fundamental to hospice, contrary to common understanding, is how to make the most out of what time remains, not how to deny care or bring life to a rapid conclusion. For my mother, we were able to take her out of bed and into a wheelchair, where she had no pain even when seated on her hip. She perked right up when she sat among the living in the day room and gazed about, despite the dense fog of her dementia. With hospice she did not have to be confined at night to a bed she sought to escape; instead a comfortable mattress was placed on the floor and her nights passed more quietly. The nursing home, with the support of hospice staff, focused not on her medical care but on kindly ministrations that enabled her to more fully feel the comfort of human caring.

Weeks passed but then her time came. When it did her breathing labored, the oxygen thinned in her blood and organs already feeble closed down. In hours, her ordeal was finally over. She had passed by the time I got a plane and arrived, as did others in my family, to prepare for the funeral the next day. There was little to do but help everyone get there and support one another since my mother had made every arrangement and paid, in advance, about every bill that death produces.  

The night after the funeral I had a dream. I was robbed when going about some noble business. Try as I might to recover my possessions, which seemed of great value, the deed had been done and there was no repossessing the goods. The injustice was what first struck me upon awakening. Loss strikes many a chord. Since then I have felt relief (for my mother, myself and my family), a melancholic heaviness, anger and greater proximity to those I love. I imagine those are openers in the process that has begun.

I also ask, and find no good answers, how the end of life might be better handled, at least in my country? Western medicine seems particularly short of effective interventions with many terminal illnesses and diseases of the brain like advanced dementia. Fighting death and disability at the end too often steals what few moments of actual life remain for someone facing imminent passing. For my family, it was human kindness and eschewing aggressive and dubious treatments that enabled our mother to savor at least a few good moments while still on this earth. But thankful as I am for that I still wonder, until we have more miracles in medical care, is there a better way than the path we are so stubbornly now on?

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A mental health recovery story about Patricia Deegan, PhD

Dr. Pat Deegan believes in her heart and from her experience that “… there is hope that those of us who have been labeled with mental illness can reclaim our dignity, can be viewed by others as people of worth, and can achieve valued social roles.”*

For many years I had heard Pat Deegan’s name mentioned with admiration, even a bit of awe. But I had not met her in person until I heard her speak at a NAMI sponsored conference in New York City some years ago where I had been asked to give comments on the talks given. When Pat stood up the crowd seemed to go very still and pay special attention. She only incidentally told her story of having been diagnosed with schizophrenia as a teenager, having lived through the loneliness and hopelessness about the terrible life that she had been told she would have by people like me, and then how she built a life with illness that has greatly advanced the recovery movement and inspired many other consumers and their families. She did this while presenting a tool she had developed by which consumers could be helped to focus and turn their psychiatric appointments into occasions for what she has termed shared-decision making. I knew then why she had earned such trust and respect among her peers. Since then I have tried to learn from and work with her so that my responsibilities as a public sector psychiatrist would be infused with what she has taught us.

Dr. Pat Deegan was not always a PhD. She had three psychiatric hospital admissions as a teenager, the first when she was 17; by the second she was told she had chronic schizophrenia and that her dreams about a life as an athlete or joining the Peace Corps were over. She writes “I was beginning to undergo that radically dehumanizing and devaluing transformation from being a person to being an illness; from being Pat Deegan to being ‘a schizophrenic.’ As I look back on those days I am struck by how all alone I was. This profound sense of being all alone only served to compound my sense of feeling worthless and of having no value. No one came to me and said, ‘Hey, I know you’re going through hell right now. I know you feel totally lost in some nightmare. I know you can’t see a way out right now. But I’ve been where you are today. I got labeled with schizophrenia and a whole bunch of other things too. And I’m here to tell you that there is a way out and that your life doesn’t have to be about being in mental institutions.”

She spent numbing months smoking, sitting, staring and sleeping. She was losing her spirit and her wish to live, not becoming suicidal but rather feeling deadness and wondering what there was to live for. Her hopes had been dashed and no one said to her that didn’t need be so.

Dr. Deegan laments how difficult it is for other people to spend time with people who are in pain, psychological not just physical. She likens the strain to that of sitting with someone who has lost a loved one to death. She points out that mental health professionals often manage their own intolerance of these feelings by “…being busy doing things to you, rather than being with you.”  She wants her peers to know that while they have an illness, “…you are not an illness. You are a human being whose life is precious and is of infinite value.” Pat Deegan understands why people with mental illnesses are angry: they have been denied the right to take risks and have failures like us all because when they do it is attributed to their illness. They have failed because they are sick, not because they are like the rest of us. That is stigma; that is discrimination. Anger is a normal response to the way we are treating people with mental disorders, she adds.

Pat Deegan is open about saying she hears voices that degrade her, that at times her thoughts are in disarray and it is hard for her to be her usual highly articulate self. Sometimes it is difficult for her to work. But whatever she feels, or thinks or hears she says “…I remain faithful to my journey of recovery. If I do that work everything else falls into place.”

A critical understanding that Pat has, and urges others to consider, is that being in recovery is not being cured. She knows her illness has not gone away. She understands that she has some limitations and by recognizing them turns her attention and her efforts to what she can do, which is formidable. She does not take medications – because that’s too passive – she “uses medications as part of my recovery process.” Similarly, if needed she does not go to a hospital (she has had 9 admissions, the last in 1994), instead she “…uses the hospital when I need to.” She adds “I have learned different ways of helping myself. Sometimes I use medications, therapy, self-help and mutual support groups, friends, my relationship with God, work, exercise, spending time in nature, all these help me remain whole and healthy, even though I have a disability. …I still have relapses but I try to understand that having a relapse is not a failure…I am breaking through into some new and scary and wonderful part of living. I am not breaking down; rather, I am breaking out or breaking through.”

The recovery that Pat Deegan describes is hard work. She is determined to live, love and contribute. So many in our field have her to thank for not abandoning her life when told she would not have a life much worth living, and that she would be of little value. Her recovery continues. She has a calling that beckons her and it is far louder than any hallucination she may hear.

*Deegan, PE: Recovering our sense of value after being labeled mentally ill, http://www.patdeegan.com

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What does it take to get something done? by Dr. Lloyd Sederer

My wife and I were at an elegant dinner party on the upper west side of Manhattan on a cold, clear wintry Saturday night when the conversation shifted to the homeless men sleeping on the steps of a church nearby. It was no surprise since our hosts and others there knew we both worked to improve the lot of the homeless in NYC – my wife through her work with supported housing and homeless prevention and outreach and I because I had worked for NYC government in the Bloomberg administration. Our hostess said,

There are these four men who have been there for weeks. My husband and I pass them most every evening and they seemed to be settling in. Why don’t they go inside? Doesn’t the City do anything, especially on a night like tonight when the temperature is below freezing? Isn’t there something called “Code Blue” where the police have to bring people inside?

One of them seems to be the leader. His name is Walter…he’s a big African-American man with earphones and lot of layers of clothing. The church doesn’t want to send them off its property – but this is unconscionable to see them living there.

Others agreed with her. They knew that “Code Blue” referred to a City law that required police to offer shelter to people on the streets when the temperature fell below freezing and bring them to shelter if they refused. But the police often had reservations. There are a lot of things that are against the law, some of which are enforced more than others. Let me take us back to a night sometime before this dinner party for an example…

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It was during a bitterly cold, icy winter night when I had my best lesson about “Code Blue” and why not all people on the street are brought in by the police and emergency personnel. I had gone out late one weekday evening on homeless outreach with a mental health agency’s community team after a street homeless person died from exposure in the City. That night the temperatures were dangerously low, killer cold. Around the country exposure deaths are not uncommon among the homeless, though more often they occur from heat and dehydration than from hypothermia. But not in the northeast. Our high-risk times are when the wind blows the artic weather from the north and deep freezes the streets and anyone unfortunate enough to not have shelter. Our team was to work the west side of mid-town Manhattan, an area that had, at that time, over 250 street homeless people. It was snowing, with fierce winds and temperatures in the teens. It was really cold, and I dressed as if I were planning to climb Everest.  

I was the Director of Community Services (DCS) for NYC, a position that placed me in charge of public mental health services for the City (also known as the City’s mental health commissioner). As DCS I had the authority to order the police to “remove” anyone deemed dangerous to him/herself (or others) as a consequence of a mental disorder. This includes people who place themselves in harm’s way from nature’s indifference to human frailty. People can die of exposure on the street, which most times can be prevented.

The conditions on that winter night might have you think that no one would remain on the streets: no one in their right mind. But not everyone in a city of over 8 million people will have the mental capacity to judge that staying outside on the street could be fatal. No one in New York City that night should remain on the street. There were the killer temperatures, Code Blue status in the City, the Police out on patrol, a recent death to heighten our concerns and attention, and outreach teams scouring for street homeless. Even the DCS was out to help ensure that no one died that night. You would think those were sufficient conditions to clear the streets.

My team found about twenty people in the zone we were patrolling, and we were able to bring all of those people into protected environments like drop-in programs and shelters. One man, sadly, was sitting on a park bench waiting for the midnight “food run” where a van usually drives around handing out sandwiches to those on the street who are hungry. We had to tell him that no van would be coming that night but we could arrange for him to have something to eat in a nearby drop-in center. He left the bench for shelter and food. The ironic lesson here is that some homeless service practices “train” people to stay on the street by feeding them there, rather than feeding them in a protected site, like a drop-in center. Good deeds don’t always produce good outcomes.

One man ran away from us. He was dressed in tatters, with a cotton shirt hanging out of torn baggy pants, shoes too big for his feet and wrapped in a thin blanket like you get in a hostel. Not the gear needed to survive a night on the unforgiving City streets. He looked frightened and agitated. We trailed him and with the assistance of the police whom we had called we finally caught up with him near Penn Station. Once two cops approached him with us he became accepting of our help, his face relaxed like when someone takes over for you when you can’t do something yourself. We were able to get him into the police cruiser and onto a local hospital.

At about 1AM we went to see a woman we had been called about who usually slept on the steps of a prominent church. We were told by the dispatch staff of the community agency that did outreach in that area to expect her to be reluctant to leave her perch, which proved to be truly an understatement. There she was on the top step of the church, the broad platform that sat atop of ten steps and provided entry to the church’s giant carved wooden doors. She was awake and fussing with clothing, blankets, and countless plastic bags that had known better days. She appeared to be in her sixties, maybe younger considering how mental illness and street living ages a person. My first reaction was that she would die here tonight if we let her stay. For all the raggedy stuff she had bundling her, it was inadequate to protect anyone let alone a tiny woman of her age. The blankets were cotton or synthetic, not wool, her jacket a frayed waist coat, she had no hat, and she wore slippers one of which was falling off a sockless foot. She was struggling with a large piece of torn plastic that refused to stay in place. I was amazed she could bear the cold. I introduced myself to her, saying I was a doctor and asking how she was. You get used to hearing ‘I’m fine’. She would not tell us her name. It was when I tried reason and explained that we were out to bring people to safety during this bitter cold and rising storm that she said,

If you want to help me, then get my key back from my landlord. I have an apartment but I’ve been locked out. That’s how you can be helpful. He had no right to do that.  

We asked where the apartment was, how long ago this had happened, could she give us more information? Her responses became more incoherent as she grew angrier and demanded that we solve her problem with her landlord – despite the absence of information she provided.

In psychiatric training we learn to meet someone where they are and help them go where they would want to go were their judgment not impaired by mental illness or some other condition. I would have my work cut out for me that night. I started with bargaining: we would help with the landlord – if we could – I said, but first she had to come in from the cold tonight for that to happen.

I need my key tonight, and I am fine here, she countered.

My next strategy was to go into medical mode. I had seen people die from exposure and as a doctor I wanted to help prevent that, I told her.  She swatted that one away, too: I know all about hypothermia, and I have prepared myself. I have been out many a night colder than this, and I have learned to survive. Nothing will happen to me, except something bad you could do to me.  

She went on speaking much like a highly educated person might, except for the remarkably bizarre gulf between what she said and the circumstances we found ourselves in. It was as if we were having an intellectual debate in a pleasant warm drawing room over tea and asking about one teaspoon or two of sugar, not yelling to be heard over the howling winds of this awful, snowy night. That was when I asked a colleague to call the police.

A cruiser came promptly. Two officers approached. I introduced myself and briefed them on the situation. I asked for their help in persuading her to come in from the cold. The ranking officer mounted the steps with me and we tried again. Once again, she was steadfast – now turning to the officer and pleading for his help to remedy the wrong she was convinced her landlord had perpetrated. It was really cold, the kind of cold that makes it hard to stand still, and I was better dressed than the police who had not planned to be out of the cruiser for long, no less trying to reason with a senior citizen on the steps of a church. Soon we knew this was going nowhere so we returned to the sidewalk to confer. I said she had to be brought to a hospital or a drop-in center, it was too dangerous for her to remain here.

The New York City Police Department responds to a phone call about what is termed an “emotionally disturbed person” (an EDP), about every seven minutes— near to 90,000 such calls a year. These include all kinds of events – Code Blues, domestic disturbances, and people behaving strangely wherever they might be. Our call had been classified as an EDP. 

After we spoke, the senior police officer made two calls. One was to his shift supervisor and the other was to the emergency medical technician (EMT) unit of the fire department that was covering the area we were in. Very soon, another police cruiser arrived as did an EMT ambulance. We were now four police, two EMTs, my three outreach colleagues, and me. That is a lot of government, law enforcement and professional firepower. The supervising police officer who had now arrived told the other officers and EMTs surrounding him that they had to take her in since I had removal authority and it was a Code Blue night. He instructed the two EMTs to gather her and her belongings for transport. The senior EMT also tried to talk with her, to have her willingly come to the ambulance. Get the hell out of here, leave me alone! You are not what I need, I need my key! Get the hell out of here, leave me alone! she shouted into the night flurries and increasingly strong winds. 

Once again we were all in conference on the icy sidewalk. I was trying to be patient, but it was hard. I had been standing past midnight for well over an hour and I was feeling the pain of the cold and growing fatigue and irritation. I wanted to be home, in a warm bed. I had to go to work in few hours. So I said, guys this is enough. Let’s get her to a hospital. She clearly is not in her right mind.

But more phone calls ensued. The senior EMT called his supervisor and the supervising police officer called his desk. They concluded, yet again, that they had to follow my order and take her from the church steps to someplace safe and warm. Remarkably, they still were not doing that. That was when I began to understand the other side of the story. The EMT said, What if we injure her when we force her to leave, break her arm or she has a cardiac event during the removal? What if she arrests {has a cardiac arrest}? She doesn’t look very well right now. The irony of the moment did not escape me since we had to remove her to safety precisely because she did not look well, nor competent to make decisions, or likely to be able to endure the night. The supervising police officer added, What if we hurt her when she resists, what if she is combative and hurt her when controlling her, or if we have to use the Tazer (a hand held device that delivers a powerful electronic current that immobilizes or can knock out a person)? She could be injured or die. Imagine that on the front page of the (New York) Post. Imagine the front page of the Post, I responded, if we leave her here and she dies tonight. I am not leaving here until she does, I added.

In the many years that I practiced in psychiatric hospitals and emergency settings I learned the quieting effect that a small group of professional people can have when they together approach someone in distress in a non-menacing way. Let’s start by gathering up her possessions, I suggested to the police and EMTs, put those in the ambulance, then all of us help her get up and assist her to join her possessions in the back of the ambulance. No more talk, no more asking, let’s just get it done. Thankfully, it worked. After we carried away her collection of plastic bags, kept talking to her, and then came back for her she went limp and did not resist our helping her to her feet and down the stairs of the church. We were able to usher her to the warm, waiting emergency vehicle and onto a nearby hospital.

As I drove home that night I thought, what does it take to something done? Look at the time and resources it took to bring into safety one terribly endangered older woman on a hostile winter night. That experience helped me understand the kinds of judgments that sometimes are made during Cold Blue nights (and other potentially deadly days and nights in NYC) that limit the protection from danger our City’s most vulnerable residents can receive. The best solution, I think, is not better enforcement of Cold Blue (though that would be a good idea) – it is doing everything possible to keep moments like these from happening in the first place. We had to get people off the streets before they and the weather reach the gravity of conditions we saw that night.

 …….

 The dinner party ended around midnight and my wife and I decided to walk over to the nearby church that our friends had mentioned. Sure enough, there were four men huddled in its archway. Each man had his spot and was surrounded by the unmistakable detritus of homelessness: black plastic bags full of who knows what, layers of stained clothing meant to provide warmth, cardboard to ease the pain of sleeping on concrete and to insulate against the gnawing cold of the stone beneath them, and torn blankets to brace against the wind that claimed no mercy. To my surprise, there were no wine or beer bottles.

We knew instantly who Walter was but he was covered over and appeared to be asleep, with earphones enveloping his head. Another man, a Latino maybe in his forties, was sitting up awake, shivering. He was dressed in a thin jacket, light pants and sneakers. We introduced ourselves to him and he told us his name was Roberto. I don’t wanna go to shelter, he said. It’s bad there, you can get beat or robbed, they won’t leave you alone once you show up…it’s filthy too. We asked if he had eaten. Not much. Did he need more clothing? How was he feeling? I’m ok, I’ll be fine, I can stay here, he said. We said not all shelters are the same, some are pretty safe and they let you be; some are more like drop-ins, safe havens, where you can warm up, get something to eat and survive the night. I said I was a doctor and was afraid that the way he was dressed he could die from the cold. Did he want us to arrange for a van to come and pick him up? We talked for what seemed like a long time, I was feeling the cold.  We couldn’t tell if Walter was listening. After a while Roberto said we could call, he would try it, how long would it take? We said soon, maybe fifteen minutes. Before we left the church stairs we tried to speak with Walter, but he didn’t respond nor did the others.

We called the homeless outreach team assigned to that part of the City and they agreed to send a van to pick up Roberto, and anyone else who would join them. Maybe they would involve the police, maybe not; sometimes that helps, sometimes it scares people and they become more resistant, the staff person on the phone said, and we knew she was right. We called back later and heard that Roberto had gone to a drop-in place for the night, but none of the others.

The great predominance of people living on the streets are transiently homeless, usually for days, often due to a cascade of misfortune like the Hollywood actor Will Smith portrayed in the film The Pursuit of Happyness. But of those who are chronically homeless, living on the streets and in shelters for years, the vast majority has serious health problems and is mentally ill or abuse alcohol and drugs. Malcolm Gladwell wrote a piece in the New Yorker about one of these people, who happened to live in Reno, Nevada, whom he called Million Dollar Murray because of the aggregate costs he incurred to his community from years of repetitive use of emergency rooms, ambulances, hospitals and other social and medical services until he died – homeless.

Some believe, my profession included, that because so many of the chronically homeless are mentally ill or abuse drugs and alcohol (which is true) that we must treat these conditions first in order to get these people out of shelters and off of the street. But it can be a mistake to confound treating an illness with doing what is most needed to meet the immediate needs of those we serve. What works and perhaps most importantly what these homeless people seek is a safe and reliable place to live. For sure, they also need treatment for these conditions but when community service agencies and their government partners demand that someone enter treatment, take psychiatric medications, get clean and sober before they get housing we fail. Those who are chronically homeless want a home; offer them that – sooner not later – and they will come in from the cold. We need to meet them where they are and then help them enter the treatment they are afraid to obtain.

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Homelessness, especially chronic homelessness, can be overcome. But it will take relentless persistence in the face of entrenched interests, outdated convictions, and competing demands for resources.

Changing beliefs and behaviors, as we discover again and again, seems the greatest challenge. Knowing what works is far from doing what works. This has been called the science to practice gap. Even as hundreds of cities across this country, Canada, Great Britain, Australia, New Zealand and even Japan implement plans for ending homelessness based on evidence of what works detractors abound and others remain invested in “how we used to do it.” We used to use ether for anesthesia too.