Silent Voices

Thoughts, Observations, and News about the Humanity of People with Mental Disorders.

  • Sexual Abuse, Drug and Alcohol Abuse, and Homelessness

    In my last post I described ways that sexual abuse in childhood affects girls during adolescence. Depression, cutting, eating disorders, and suicidal behavior are all common. And so is the use of drugs and alcohol. These girls often take amphetamines and cocaine to lift their spirits, counteract their chronic boredom, and treat their depression. They take heroin to calm themselves down and temporarily forget their current worries and their painful pasts.

    Many of the homeless women I interviewed on the street with histories of childhood sexual abuse became dependent on drugs. Almost all began drinking or taking drugs as teenagers and had severe habits by the time they were adults. Their attempts to self medicate came at a steep price. Drugs destroyed their will to live, added to their shame and guilt, crippled their cognitive functions, and made them unemployable. With no means of economic support, and no support from their families, they ended up on the streets before they were twenty-five. Homelessness, in turn, led them to increase their drug use because altering their mental state with drugs was one of the only ways they could tolerate their grim lives on the streets. Many of them, after having been abused as children, became victims repeatedly in their adulthood since homelessness inevitably put them in dangerous situations.

    The lives of many of the women I interviewed reveals a pattern: sexual abuse in childhood, drug abuse in adolescence, and homelessness in adulthood. While this is a gross oversimplification that leaves out many other factors, the theme is unmistakable.

    Barbara told me that “there was suspicion that she had been molested” by her father. She began taking drugs in adolescence. To support her heroin and crack habit, she turned to prostitution and serious crime and became homeless at the age of eighteen. Sabrina was abused by her stepfather, began drinking seriously as an adolescent, and became homeless after her boyfriend began using drugs. Rose, who had been sexually abused by at least one of her mother’s boyfriends, developed a severe heroin habit in her teen years and began living on the streets when she couldn’t keep a job. Heidi was molested by her stepfather, ran away from home, developed a severe crack habit as an adolescent, and was living under a bridge when I met her as an adult.

    Bridgett’s life began and ended in tragedy. She was abused by her father and began drinking seriously in late adolescence. Against all odds, she managed to get a good job, get married, and have children. But then her daughter was raped, and the ghosts from her childhood surfaced. She was undone. In her words,  “I fell from the Empire State Building to the curb. I kept thinking about my childhood and how confusing and lonely parts of it had been. I got depressed and was crying a lot. I began to drink more and more. I couldn’t fit a wine bottle into my purse, so I started drinking hard liquor, and I could drink all day. I lost my job and my house. I left my daughter with my husband, but I never went back to get her because I was living in my car. How could I take care of her if I didn’t have a place? And then I drank even more. I was like counting on the alcohol. I wanted to forget what had happened to my daughter and everything else.”

    Over the following years Bridgett’s alcoholism became worse, she entered and failed several rehab programs, but at some point she was rescued by a social worker from a mental health program. She received a great deal of support from this person, who also helped her obtain a comfortable apartment. Despite this, at the age of forty-five, soon after I met her, she was found dead in a stranger’s apartment. She had drunk herself to death.

    I hesitate to end this post on such a sad note, but along with my optimism about the possibility that people can be helped with the right kinds of support, I am also realistic about the limits of this.

    I would appreciate your reflections on this.

    Continue reading →
  • Sexual Abuse and Adolescence

    In my last post I described some of the experiences of women I interviewed who had been sexually abused in childhood to explain how their abuse ultimately led to their homelessness.

    Many of these women, as children, reacted to their abuse with intense feelings of guilt, shame, depression, and mistrust of adults. Their “spiritual connection” to the universe as a basically safe space had been badly shaken. They lost the conviction that they had the right to a good life. Danger and hurt rather than protection and safety were what they had come to expect. Their capacity to form deep, intimate, and healthy attachments to other people was seriously affected. Often their capacity to plan, see situations clearly, solve problems, and deal constructively with their impulses was weakened. Many, despite obvious expressions of distress, received no help and entered their teen years deeply compromised.

    Adolescence for all children represents a sharp turning point in development. Children’s emotional lives and social contexts undergo tectonic and sometimes violent shifts.

    Changes in their bodies make it impossible for teenagers to hide the fact that they are now sexual beings. For those who have been sexually abused, this often intensifies their guilt and shame. Instead of feeling virtuous as human beings, they frequently feel indelibly corrupted. They have trouble truly believing that they had not been complicit in their abuse, although they actually had been powerless to resist. They can’t forgive themselves despite the fact that they stood little chance against threats of violence or loss of love, or against their own need to protect a perpetrator to whom they were attached.

    So important are love, protection, and safety in the development of a sense of identity that children who haven’t had them can’t really figure out who they are when they reach adolescence. To compensate for this, they may create a “false self” as they try on identities that are not really theirs. They may seem inauthentic and be tough to get to know intimately, which adds to their difficulty in forming healthy attachments. They may engage in behaviors that they don’t feel are truly connected to themselves because their sense of self is so fragile and so fractured. And without a real sense of self, they have little real autonomy. They remain indentured to the effects of their traumatic pasts.

    To buttress their sense of self, they frequently try to mimic others, behaving in a chameleon-like manner. They often become very vulnerable to both the power of their own impulses and to the social pressure of their friends. Their judgment becomes less about what is good for them and more about what will calm their painful feelings and be acceptable to their peers. Their ability to navigate the world safely is compromised as a result. They begin to engage in high-risk behaviors that have profound consequences.

    These behaviors are intensified by another fact of adolescence. Since these children are now able to shift for themselves without their parents’ logistical help, they can do things that their parents don’t know about. Children who have been abused can act out their distress with very limited intervention by the adult world.

    Many of these adolescents use a psychological defense called dissociation that enables them to feel separate and detached from the pain of their actual experience. They first develop this as an immediate response to their abuse in childhood, as it helped them endure what was happening. But as adolescents they often come to use this as a defensive strategy in a variety of other upsetting situations. They detach themselves and float above it all. While useful in reducing inner stress, this has serious consequences for their capacity to test and weigh reality. They fail to recognize the risk in situations and heedlessly act in self-destructive ways.

    Sometimes this takes the form of precocious and risky sexual behavior, and girls become pregnant. Sometimes they try to hurt themselves, passively or actively. Not only is this a cry for help, but it is also an attempt to excise, once and for all, the painful emotional residue of their abuse.

    Women who had been sexually abused as children have told me that adolescence is when they began to exhibit overt symptoms of distress. Some developed severe headaches and stomach pains. Others began cutting themselves—with razors and knives. Cutting was not just to get attention but to cope with their stress and overcome the numbness created by their dissociation. So adept were these children at separating themselves from their feelings that they usually didn’t experience physical pain from this cutting.

    Others turned to food to try to control their lives and moods, some starving themselves, some alternating between binging and purging. The more adults tried to influence their eating patterns, the more these adolescents resisted. They simply couldn’t afford to surrender a device that was so successful in altering their moods, distracting them from their abusive histories, gaining the attention of adults around them, ameliorating their feelings of guilt, and giving them a sense of control over their lives, however illusory. Such little control did they have at the time of the abuse that clutching onto binging, purging, and self-starvation as forms of power became almost irresistible.

    Almost all the homeless women I interviewed for my book began using drugs during their teen years. Drugs were hard to resist. I’ll discuss this at greater length in my next post because it is such a common steppingstone on the road to homelessness.

    Continue reading →
  • Childhood Sexual Abuse and Its Link to Homelessness

    Homelessness has become a tragically familiar part of our national landscape. While life on the streets is grim for both men and women, homeless women have a particularly difficult time. The struggle they face often extends back to their childhoods. A surprisingly large number of homeless women have suffered sexual abuse and severe neglect as children. At least 40 percent of the homeless mentally-ill women I interviewed for my book Silent Voices: People with Mental Disorders on the Street reported this. I say “at least” because many women didn’t want to talk about their pasts, so the 40 percent figure is probably conservative. Most abused girls don’t become homeless. However, some do. In the next several blogs I’ll discuss the effects of sexual abuse on children and teenage girls to illustrate how these traumas sometimes lead to a life on the streets as adults.

    People are often surprised to learn just how prevalent childhood sexual abuse is. Studies, using different definitions, report that 25 percent of women had been sexually abused as children. Factors that seem to influence the impact of the abuse on the child’s life include when it happened, the duration and intrusiveness of the abuse, the relationship of the abuser to the child, and the presence of protective adults. Many girls, particularly in the case of moderate to severe abuse, show signs of detachment, social isolation, and mistrust of adults. They may have insomnia and nightmares, and may find it so difficult to concentrate that they fall behind in school. Depression, anxiety and dissociation are also common consequences. In what can only be regarded as a cruel irony, many girls feel ashamed and guilty, sometimes feeling complicit, despite the fact that they are the victims not the perpetrators of this abuse. The resultant conviction that they have no right to live a good life is often the most powerful and destructive consequence of this, affecting the entire course of their lives.

    In many cases the child feels too frightened, ashamed, or guilty to disclose what is happening to her. When a father or stepfather is the abuser, the girl may feel, in addition, that she needs to protect him, either out of love, fear, or other feelings. Sometimes the child’s mother is so distracted by the problems in her own life that she fails to recognize that she is actually putting her daughter in harm’s way. If and when she does, she may turn a blind eye to what is happening, wanting to protect her own relationship with her husband or boyfriend.

    Most abuse is not recognized by schools, churches, welfare agencies, or other organizations. A teacher may see a child’s symptoms of distress or that she is falling behind but not connect it to the possibility of abuse or not want to stir up trouble in the absence of hard evidence. When teachers do make the connection and report their suspicions to a welfare agency, the latter often can’t obtain compelling evidence in the absence of the child’s willingness to disclose the cause of her suffering. In other scenarios, the agency is simply too burdened with more obvious cases and lacks the resources to conduct the kind of patient, sensitive, thoughtful investigation that is needed to confirm everyone’s suspicions in the less obvious ones.

    But documenting the abuse is just the first step in a long process. Even when a positive conclusion can be drawn, the question of what to do about it is always complicated. Should the child be removed from the family? Should the father or stepfather, if the perpetrator, be removed from the house or sentenced to a prison term? How should the courts be involved, and how should they gather and sift the evidence? What kind of treatment should the child receive? Where can programs be found that have staff who are experienced enough to provide such treatment? These questions may seem to have obvious answers in the abstract, but not in the nitty-gritty of real-life situations.

    Of the homeless women in my book, Barbara was abducted and abused by her father. Rose was abused by several of the men her mother brought into the house. Rebecca was raped by her stepfather so viciously that her vagina needed to be repaired in the emergency room. Other women told me they had been abused but didn’t feel comfortable relating the specifics. All of the women I interviewed who had been sexually abused and became homeless had experienced this abuse in a situation that was also profoundly neglectful. No one was present to protect the child. In almost every one of these situations, it was the combined effects of abuse and neglect that had such enduring effects. Each of the girls was forever scarred. Each entered adolescence traumatized and ready to act out in various ways.

    In my next post I will discuss how this abuse often plays out when the girl becomes a teenager.

    Do you know someone with a similar story?

    Continue reading →
  • Who Are the Homeless?

    As I walked down Market Street in San Francisco early one morning I saw many people lying on the sidewalk. It got me wondering whether I was seeing a representative sample of people who are homeless. I thought it might be useful to look at some national data and to sort it in different ways that shed light on who the homeless are.

    In case this post is too ponderous and detailed, let me summarize it up front.  Then you can wade through it if you want the details:

    1. People we see on the street generally have no shelter of any kind, have mental-health and substance-abuse problems, are chronically homeless, and have a particularly hard time climbing out of homelessness. The other homeless people tend to be families who have become homeless because of some kind of economic collapse, are homeless for a short period of time, and tend to be invisible to the public because they’re living in some kind of housing situation, however uncomfortable.
    2. The homeless population has decreased substantially over the past three or four years due to the improvement in economic conditions and federal housing initiatives. Homelessness is not an inherently intractable problem but reflects the lack of political will to do anything about it.

    First let’s review the four broad categories of people listed in the federal definition of homelessness:

    1. “People who are living in a place not meant for human habitation, in emergency shelter, in transitional housing, or are exiting an institution where they temporarily resided if they were in shelter or a place not meant for human habitation before entering the institution.”
    2. “People who are losing their primary nighttime residence, which may include a motel or hotel or a doubled up situation, within 14 days and lack resources or support networks to remain in housing.”
    3. “Families with children or unaccompanied youth who are unstably housed and likely to continue in that state.”
    4. “People who are fleeing or attempting to flee domestic violence, dating violence, sexual assault, stalking, or other dangerous or life-threatening situations related to violence; have no other residence; and lack the resources or support networks to obtain other permanent housing.”

    According to a 2013 federal HUD point-in-time report, about 610,000 people in the United States were homeless on any given night.  Of this number, 222,000 are people in families and 388,000 are individuals living alone.  A remarkable 23 percent of the total homeless population are children under the age of eighteen.  Most of these kids live with their homeless families but some live alone and have left their families due to a disruption, divorce, abuse, or neglect.

    Homeless families tend to be invisible to the rest of us because they usually are living in some form of temporary shelter, car, motel, or other transitional arrangement such as temporarily living with other families or their extended family. This group of people usually becomes homeless through a serious financial reversal (loss of a job, eviction, medical condition that prevents the breadwinner from working), tend to be homeless for only a short period of time, and bounce back to stable housing with rent assistance, housing placement services, and employment support.

    Of the 610,000 homeless people, 18 percent (or 109,000 persons) are chronically homeless: they have been homeless for one year or longer or experienced at least four episodes of homelessness in the last three years and have a disability.   Chronically homeless people tend to have a high incidence of mental-health and substance-abuse problems, and are generally those we see sleeping on the street.

    Looked at another way: of those people who fit into the federal definition of homelessness, approximately 60 percent (or 370,000 persons) have some degree of shelter even if this is primitive, uncomfortable, and temporary, and 40 percent (or 240,000 persons) have no shelter of any kind and sleep on the street.   It is likely that the majority of this latter group, the group we most closely identify with homelessness, are individuals who are chronically homeless, have a mental illness or drug-abuse problem, and have very little chance of escaping from this condition.

    So I was right to be skeptical of the tendency to equate the people we see sleeping on the street with the entire homeless population.  The people sleeping on the street, though reflecting a great deal of human tragedy, actually represent a minority of the homeless population.  Of course, the other implication of this data is that the full extent of the problem is largely hidden from public view since most homeless people, those who have some form of shelter, tend to be invisible.

    Some good news: largely because of government housing assistance and an improvement in the economy, the number of homeless people in the United States has declined in the last three years. Between 2010 and 2013:

    1. Total homelessness decreased by 6.1 percent.
    2. Chronic homelessness among individuals declined by 15.7 percent (or 17,219 persons).
    3. Homelessness among individuals declined nearly 4.9 percent (or 20,121 persons).
    4. Homelessness among persons in family households declined by 8.2 percent (or 19,754 persons). This decline is entirely composed of unsheltered people in families.
    5. Veteran homelessness fell by 24.2 percent (or 18,480 persons).

    This data leads to the heartening conclusion that when there is enough political will and the funds to carry it out, the so-called “intractable” problem of homelessness, including chronic homelessness, can be solved.  It also leads to the conclusions that we need to do much more than we’ve done and that this is likely to bring results.

    In another blog, I’ll describe the complex reasons for homelessness, because the solution to the overall problem will consist of many different initiatives that are tailored to specific subgroups within the homeless population.

    Let me know what you think about what the government is doing: what seems to be working and what isn’t.  And what needs to be done.

    Continue reading →
  • “Silent Voices” Blog

    Welcome to the launch of my new blog, “Silent Voices.” I have been interested in people with severe mental illness throughout my professional career, from before the time I was commissioner of mental health for Vermont and Massachusetts through my 17 years as chief of psychiatry at San Francisco General Hospital and professor of clinical psychiatry at UCSF. The publication of my book, Silent Voices: People with Mental Disorders on the Street, which examines the phenomenon of mental illness on our streets today, has given me the impetus to also start this interactive blog. It is my hope that it will stimulate conversations about important mental health policy issues with an emphasis on those that relate to people who struggle with severe mental illness and sometimes homelessness. I look forward to hearing from you.

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for Dr. Okin’s blog, Silent Voices, which consists of observations about important mental health news and policy issues, and selected announcements related to the book itself.