This article is based on my experience treating chronic mentally ill men in the Fort Washington Armory Men's Shelter in the Washington Heights section of New York City over the past ten years. During the first five of those years, I completed psychoanalytic training at the Columbia Center for Psychoanalytic Training and Research, just a block from the shelter. A shelter for homeless men might seem like an unlikely setting for a psychoanalyst to apply the tools of his trade, but along with many of my colleagues who work in the community, we do not surrender our analytic identities when we work as community psychiatrists. To the contrary, a dynamic understanding of our patients, the patient-case-manager relationship, and staff interactions informs our work on a daily basis. This holds true whether we are serving as direct providers or supervisors.
Where someone might describe a patient as “manipulative,” we look for the transference. When a case manager who works with the homeless mentally ill feels he is suffering from “burnout,” we explore the countertransference. When others view a patient simply as “non-compliant,” we explore defensive operations, the compulsion to repeat, the role of identity diffusion, or disturbances in self and object representations.
We are all familiar with the case of Ed. Ed's parents suffered from hallucinations telling them of great tragedy that would befall the family in the future. In response to these voices, they physically abused and abandoned Ed. By some good fortune, the guidance of others, and the strength of his determination, Ed survived, but he was destined to wander the land on his painful, swollen feet.
Freud, we know, chose to use the case of [O]Ed to illustrate the fundamental unconscious conflicts faced by all who are destined to suffer from neurosis. However, we can also see in the life of Ed the fate of an alarming number of abused, neglected, and sometimes abandoned children who become homeless adults. In his 1963 paper, “The Parent as Sphinx,” Shengold compares Oedipus to the children of abusive psychotic mothers. Although not all homeless adults suffered from the kind of abandonment experienced by Ed in his childhood, several studies now confirm that risk factors for adult homelessness include childhood experiences of out-of-home placement, residential instability, parental mental illness, parental substance abuse, violence in the home, and shifting caretakers.
It is typical for patients from New York City shelters to have been raised by a single mother, an aunt, a grandmother, or a series of foster parents. Often, the homeless experience the repeated trauma of being passed along from one reluctant caretaker to the next. This childhood trauma is frequently replicated in the homeless adult's experience in shelters, prisons, hospitals, and on the street. It should not surprise us, then, when we encounter in many of the urban homeless serious developmental deficits, primitive defensive operations, self-pathology, and marked impairments in object relations. A large proportion of the homeless suffer from conditions Kohut termed “primary disorders of the self.” These include severe personality disorders, addictions, psychoses, and depression. In a study examining the diagnoses of the schizophrenic men I treat in the Ft. Washington Men's Shelter, Caton et al. found that many of the men suffered from coexisting substance abuse and antisocial personality, the so-called triple disorder. The presence of character pathology complicates the treatment of the Axis I psychiatric disorders and substance abuse often seen in the homeless.
Whereas psychoanalytic theories once occupied the forefront of our understanding of psychosis, we now live in a time when community mental health suffers from what Joel Kantor, in his 1990 paper, “Community-Based Management of Psychotic Clients: The Contributions of D.W. and Clare Winnicott,“ called a ”conceptual vacuum.“ As biological therapies emerged and treatment shifted from the hospital and office to the community, valuable contributions by psychoanalysts to the understanding of psychosis and the treatment of patients with chronic mental illness were frequently neglected. (E. Fuller Torrey's Nowhere to Go: The Tragic Odyssey of the Homeless Mentally Ill is an example of this critical attitude toward psychoanalysis.)
Psychoanalytic theory can help inform treatment of homeless patients at all stages. Typically, work with the homeless involves an initial outreach phase during which the focus is on establishing a trusting relationship, after which other services can be offered The second phase, where
Alan D. Felix, M.D. is Director of the Columbia-Presbyterian Critical Time Intervention Mental Health Program. He is Assistant Clinical Professor of Psychiatry at the Columbia University College of Physicians and Surgeons, and he is on the faculty of the Columbia Center for Psychoanalytic Training and Research.
medication might be given, benefits procured, social skills honed, and housing applications completed, comprises treatment proper. Finally, there is the stage in which the patient makes the transition into community-based housing.
Outreach teams are now widely recognized as essential for establishing treatment relationships with the homeless. As with any treatment, a successful outcome depends on the therapist being attuned to the patient's wishes, fears, fantasies, needs, and desires, especially at the beginning and end of treatment. A therapist or case manager, like a good-enough mother, must be in sync with the developmental phase of the patient's psychological self. For simplicity, in this discussion I refer to outreach workers and case managers as “she” and patients as “he.” In the beginning stage of treatment with the homeless mentally ill, the outreach worker positions herself between the patient and the environment. As Winnicott, Modell, and others have pointed out, establishing a holding environment is necessary for treatment to unfold. The outreach worker has the challenging task of entering the homeless person's world without intruding. Many of the homeless, driven by the cognitive, perceptual, and emotional distortions of their mental illness, combined with experiences of rejection, abuse, or neglect, withdraw from the world at large.
A holding environment is frequently established by offering concrete goods initially. Food, cigarettes, clothing, or blankets provide physical comfort while satisfying basic needs for maternal support. Like the good-enough mother, the outreach worker helps to modulate the patient's affective experiences, gently pulling him from his cocoon-like world into a world of others. Moving too aggressively toward the patient will cause a heightened anxiety, causing him to withdraw again, while moving too slowly can cause undue frustration and feelings of neglect.
Many outreach workers and case managers carry out these tasks under the guidance of a good intuitive, empathic sense. However, the principles of outreach can be taught using psychoanalytic theory as the conceptual framework that informs the action taken by providers.
Once a holding environment is established, the basic tasks of treatment with the homeless mentally ill can proceed. With a background of trust and safety, the case manager can begin to direct treatment toward establishing permanent housing and ongoing treatment. Including the psychiatrist in the initial engagement process facilitates the patient's acceptance of medication. Unfortunately, many programs can only afford to use psychiatrists for brief, monthly visits.
As with any treatment, outcome depends so much on the management of transference and countertransference. Here is where the analyst as supervisor can be uniquely effective in the community. Extreme transference reactions, including potentially dangerous acting out, are par for the course in treating the homeless mentally ill. Typical countertransferential responses to homeless patients include withdrawal from the disaffiliated, schizoid patient; frustration and hatred towards the help-rejecting, devaluing, grandiose patient; feelings of helplessness or compensatory rescue fantasies with dependent patients; and fear, flight, or vengeful feelings toward the paranoid or aggressive patient.
“The outreach worker has the challenging task of entering the homeless person's world without intruding. Many of the homeless, driven by the cognitive, perceptual, and emotional distortions of their mental illness, combined with experiences of rejection, abuse, or neglect, withdraw from the world at large.”
Kohut's concepts of the mirror transference and the idealized parental imago are especially relevant to work with the homeless. These transferences are readily demonstrable and are easily understood, even by nonprofessional staff. To illustrate these transferences and how an understanding of them can be used to guide very practical decisions, we can look at the cases of Charles and Pete.
Charles is a thirty-year-old Haitian man who spent several years in a municipal shelter. At an early age, his father left the home and his mother suffered a “breakdown” of some sort. Charles moved among relatives who were reluctant to care for him and foster care, until he was finally sent to live with a loving grandmother in the States. When he entered a psychiatric day-treatment program in the shelter, he was unkempt, his thought process was loose, he was using crack cocaine, and he was responding to auditory hallucinations. His case manager was beginning to feel pessimistic that Charles would ever improve. Then one day she noticed Charles speaking French while he applied lipstick and gazed in the mirror. After observing for some time, the case manager gently asked Charles who he was speaking to. Charles responded, “Ma grand-mere.” In supervision, the case manager reported that, as a result of the incident at the mirror, she learned about Charles's positive relationship with his grandmother. Rather than view Charles's behavior as aberrant, it was explored as a rather concrete representation of a mirror transference. Aspects of Charles's good self were reflected in the representation of the caring self-object, personified by the grandmother and case manager. Recognizing this, the case manager immediately thought of a matronly woman she knew, Ms. T, who ran a boarding home. A visit was arranged, topped off by generous portions of Ms. Ts home cooking. For the first time, Charles was excited about moving out of the shelter. He agreed to follow Ms. Ts rules for living at the boarding home — that he must take medication and attend a substance-abuse treatment program. After showing some improvement on antipsychotic medication, Charles became a boarder at Ms. T's.
Pete was a single African-American man in his mid-thirties when he entered a shelter-based treatment program. When Pete was five, his father died suddenly, leaving the mother to care for Pete and his four siblings. After suffering a psychotic break in college, Pete lived in the street or shelters for years, his schizophrenia untreated. In the treatment program, he refused to take medication for quite some time, but he was gratified by his role as the keeper of the minutes of the community meetings. Pete's love of writing and politics led him to produce reams of notes, commentary, and an occasional short story. The program director and psychiatrist met with him daily to discuss his observations.
In one psychotic yet poignant short story, Pete wrote of a “wounded animal with its scars,” and he referred to “struggling for truth” and “being delivered” in the treatment program. These references were understood as illustrative of his narcissistically wounded self and his idealization of the program, especially its director and psychiatrist. When the program director left for another job, Pete also left the shelter. He began to sleep in the street near where his family was living. When he visited a sister, he was lice-infested, malodorous, and quite psychotic. The sister called the psychiatrist, who arranged a family meeting. Pete agreed to return to the shelter and meet with the family. Clearly, the loss of the director-father led him back to his family of origin. However, he had a similar paternal transference with the
psychiatrist and was pleased to be reunited with him. The mother flew in from another country to attend the family session, which was held in the shelter. Bolstered by this moving show of support, Pete accepted the psychiatrist's recommendation to begin antipsychotic medication as a condition for continued contact with his family. After significantly improving on medication, Pete was placed into supportive housing. After two years there, he married another resident, and they later moved into their own apartment.
Here again, the transference was not interpreted, but it was used to inform both the timing and form of the treatment provided. As Kohut has described, the process of transmuting internalization that occurs when a self-object transference forms leads to the development of greater ambition and consolidation of the nuclear self. In the case of Pete, a case management team approach safeguarded him against the repetition of a childhood trauma by providing more than one figure to serve as an idealized parental imago. Not only did the psychiatrist serve this function in the director's absence, but the program itself served as a self-object, a transitional “home” of sorts.
While these cases illustrate a self-psychological perspective, other dynamic frameworks can be usefully applied. For example, understanding the role of aggression in the formation of primitive defenses, such as splitting and projective identification, can be useful to the case manager who is dealing with a homeless patient with a borderline personality organization. Regardless of one's dynamic orientation, understanding the transference and countertransference enriches the patient/case manager relationship, informs practical decisions in the treatment setting, and helps to contain potentially destructive acting-out behaviors.
This final stage in the treatment of homeless individuals is frequently the most challenging and emotionally charged. After the formation of an intense relationship with the patient over months or even years of street outreach or treatment in a shelter, outpatient program, or drop-in center for the homeless, the transition to housing often means a termination of that relationship.
From 1990 to 1994 I was fortunate to participate in an NIMH-funded study called “The Critical Time Intervention,” or CTI. CTI involved continuous treatment by a case management team for up to nine months following placement from a shelter into housing. The study employed a randomized case control design and demonstrated that continuous case management, in comparison to making referrals to all new providers when the patient entered housing, reduced the rate of return to shelters or the street threefold.
I believe that much of the success of the CTI program can be attributed to its incorporation of fundamental psychoanalytic principles of development and change. An unexpected finding of the study was that we were able to follow patients for up to eighteen months after placement in housing. Only two of ninety-eight subjects, both in the control group, were lost to follow-up. This is a testament to the enduring relationships that our patients formed with the treatment team, especially with the primary case managers. The most obvious aspect of CTI that distinguishes it from most systems of care during the era of deinstitutionalization is that treatment is continuous over space (from the shelter into the community) and time (for a transitional period of up to nine months). Unlike other systems, patients are not “dumped,” nor are they followed forever. The nine-month limit offers practical advantages, such as cost-effectiveness and ongoing enrollment of new cases, and the effects of CTI lasted for the full eighteen-month study period (i.e., nine months after the intervention was stopped).
In addition to the practical advantages, there exists a dynamic rationale for CTI that has many parallels to Mahler's developmental stage of separation-individuation and its subphases. Before housing placement, patients must demonstrate certain ego strengths and behaviors typically referred to by workers in the field as housing readiness. The case manager looks for improved hygiene and social skills, improved reality testing, a greater awareness of the illness and substance abuse problems, acceptance of medication and other therapies, and motivation to achieve a greater degree of autonomy (not to be confused with withdrawing from society). The latter might be signaled by the patient's wish to move into housing, obtain a high school equivalency diploma, or enter a vocational rehabilitation program.
The period of housing readiness, combined with the first few months following the actual move to housing, can be compared to Mahler's differentiation subphase. Whereas the infant is propelled by the development of motility, the homeless mentally ill patient gains a psychological “motility” that is expressed in his desire to leave the “security” of the street or shelter and the relationship with the case manager. This movement away from the case manager is often countered by return visits to the shelter, what Mahler might have called “checking back,” a process that is not only allowed by CTI, but encouraged. Medication prescriptions and parting gifts, such as articles of clothing, appointment books, or certificates of achievement, serve as transitional objects. Thus the key ingredient to CTI is an empathic, phase-appropriate separation, in contrast to the patient's previous experiences of traumatic loss and rejection.
The second trimester of the nine months of CTI is referred to as the practicing phase. The gist of this phase is the establishment of a firm network of supports and providers in the community. The CTI case manager takes a less active role in providing services. Rather, she “steps back”, like the mother of the toddler in the practicing subphase, watching the patient negotiate his way through his newly discovered environment. The case manager is there if the patient “falls,” but she gives him room to explore and develop new attachments. If all goes well, the patient experiences a burst of motivation as he surrenders his demoralized homeless self in favor of a new, hopeful, more consolidated self with a sense of “home.” For some patients, however, the process of separation that comes with housing creates a crisis that breeds regression. These patients typically relapse into substance abuse, stop taking medication, or drop out of treatment altogether just prior to, or shortly after, obtaining housing. The real danger during these crises, aside from the patient's self-destructiveness, is that the case manager is apt to feel frustrated and vengeful, perhaps even giving up on the patient. Recognizing the role of the patient's fear of object loss during what amounts to a rapprochement crisis is an essential step in turning the treatment toward more positive outcomes.
During the CTI study, several patients returned to the shelter after housing placement. This occurred in both the experimental and control groups. However, the experimentals, under the guidance of their CTI case manager, were able to return to housing in significantly less time than the controls. I believe this can be explained by more than just the concrete services offered. The enduring CTI relationship provides the opportunity to resolve the rapprochement crisis and resume the steps toward a greater degree of object constancy. For those patients who follow a smoother transition to housing, the CTI case manager and the shelter-based program provide the refueling station the patient needs as he adapts to his new world In the last months of CTI, the case manager is, to use Mahler's words again, “quietly available” to the patient and new providers. As the intervention draws to an end, parties and rituals mark the time as the end of one era and beginning of another, much like the separation-individuation stage of development.
I am frequently asked how I can tolerate the despair of working with people who are so down and out. To the contrary, treating the homeless offers an opportunity to see significant life changes in a relatively brief period. Psychoanalytic training has enriched my understanding of this process of change. Interestingly, working with the homeless has given me a greater appreciation of all my patients' fears of object loss, sometimes expressed in fantasies of becoming homeless, or as Sophocles described Oedipus, “a wanderer, not a dweller in the land.”