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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 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...
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 20 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 teams "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. When two cops approached him with our support 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 1 a.m. 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 60s, 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.
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 told her that I had seen people die from exposure and as a doctor I wanted to help prevent that. 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 regrouped on 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 regarding 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 board 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.
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 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 able to endure the night. The supervising police officer added, "What if we hurt her when she resists, what if she is combative and we hurt her when controlling her, or if we have to use the Taser? 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 my many years of work 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 Code 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 Code 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 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 40s, 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 15 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 Happiness. But of those who are chronically homeless, living on the streets and in shelters for years, the vast majority have serious health problems and are 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.
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.
The opinions expressed herein are solely my own as a psychiatrist and public health advocate. Lloyd I Sederer, MD
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