TEN

Alcohol, Drugs, and Insanity

There is no gainsaying that many homeless people are alcoholic or addicted to illicit drugs or insane. But I think the proportion of homeless people who belong to one or more of those categories is greatly overestimated.

This overestimation seems to stem from two otherwise opposing views. People who do not want to help the homeless seek to blame the homeless for being homeless. These people see alcoholism, drug addiction, and insanity as character flaws that somehow justify the condition of the homeless. This conservative line of thought is only one step removed from the conclusion that in addition to deserving homelessness, the homeless also deserve whatever mistreatment individuals or society may choose to mete out.

Those who wish to help the homeless, on the other hand, want to find a problem that can be fixed. Admittedly, alcoholism, drug addiction, and insanity are difficult problems, but something can be done about them. What is even better, for those who take the liberal view, is that what can be done for alcoholism, drug addiction, and insanity is likely to involve the creation of many jobs for social workers and administrators and other middle-class people. Although they find contradictory morals to it, both of these views subscribe more or less to a mythical history of the typical street wino. It is a myth that goes something like this: A man had a reasonably good job and reasonably happy home life. But he drank. At first it was only social drinking. But he drank more and more because he had either the disease of alcoholism or a character flaw that deprived him of the will to be sober, depending upon whether the myth is told in its liberal or its conservative version.

At any rate, he covered up his drinking for a while, but eventually everyone else realized he had a problem. Something dreadful happened at work, at home, or on the road, and the alcoholic had to admit, at last, that he might have a problem. Perhaps he tried one program or another, but without success because—as they say in the programs—he had not yet hit bottom. He lost his job, his family, and at last his home. And there he is, a wino clutching a brown sack, passed out in an alley.

Indeed, I met street winos who told this story of themselves. But in as many other cases I found the cause and the effect reversed: people who claimed to have drunk little or not at all until they became homeless.

Alcohol in some forms is cheap and readily available to people on the streets. The winos in El Paso favored Mogen David 20/20. In Austin, Wild Irish Rose was a favorite. The law in Texas requires a special license to sell wines with an alcohol content of more than fourteen percent, but every convenience store has one or two brands of wine that push as near this limit as possible. These products, of course, are not much sought after by oenophiles and are seldom served at intimate dinners. In Los Angeles, corner stores could sell liquor and I noticed the preference for wine was much less pronounced. For reasons I do not understand, malt liquor is favored in some black areas.

I do not propose to try to convince anyone that homeless people buy alcoholic beverages out of thirst, but many times when I could not find a water tap and had to buy something to drink, I noticed that whichever beer was on sale was cheaper than soft drinks or mineral water. I hope this will not be taken to imply that beer should be made more expensive, for my complaint is of the difficulty of finding nonalcoholic drink. When I could find it, distilled water was cheaper, but it would be found warm, on an out-of-the-way shelf, in unwieldy, unresealable plastic gallon bottles. Except that Lizbeth despises beer and I would not give a dog beer anyway, I am fairly sure I would have asked myself on several occasions: Why not get the beer?

Why not, indeed. Alcohol provides a sensation of warmth and well-being. In truth, alcohol can contribute to hypothermia in the winter and to dehydration in the summer, but many people, homeless and not, are unaware of this. Alcohol is a fair anesthetic and its sedative properties can produce sleep in restless circumstances. Alcohol induces the illusion of potency in the powerless—I can identify, but not quite understand, a nexus of alcoholism and issues of power, else why would so many politicians be alcoholic. In a life that seems utterly without meaning and purpose, the quest for the daily dose is something to do, is a reason to keep putting one foot in front of the other. Perhaps many people, perhaps all people, deceive themselves in some way or another to make it through the day, to the end of the quarter, to the closing of the fiscal year, to the season when the children leave for college. So a homeless person may become a wino by deceiving himself that paradise is at the bottom of the next jug.

If there were no alcohol, society would still have no use, no job, no home for the men, young and old, who sit on street corners with brown paper sacks. If the cities were filled with sober hopeless people, I doubt that the comfortable would find the results much to their liking.

So long as I had hopes of improving my position, I avoided other homeless people. I did not want to be acculturated to the street or resigned to my situation. Beyond this, I often avoided other homeless people because alcohol was the organizing principle of the street life I saw.

According to my observations, the homeless, aside from the whole families I saw in downtown Los Angeles, occur as loners, like me, or in pairs, or in groups of six to a dozen. Loners who were alcoholic tended to be in an advanced stage of alcoholism. When there was a pair, one of the pair was the star and the other was the sidekick, but I never detected any particular pattern of alcohol use among the pairs. There were also relatively stable groups of men who occupied more or less fixed areas. In some of the groups the men camped together. Eight seems to be near the optimal number of members in one of these groups—much larger groups, I surmise, would have been perceived as a threat to the peace. I never ran into such groups of men that alcohol was not present. Some of the men in these groups certainly were thoroughgoing alcoholics. But many others cared as much or more for the company. Whatever alcohol any one of them had was shared, and everyone was expected to drink. The men who seemed to care less for the alcohol tended to be younger, to have some gear, and to exhibit, usually, some sign of caring for their appearance. Also, sometimes they got drunk, whereas those whom I identified as alcoholics did most of the drinking but were hardly ever drunk.

The men in these groups shared with society at large the belief that every homeless man drank. As I refused to drink with them I could not gain any acceptance from these groups. Over the course of many weeks one man from one of these groups offered me drink whenever I met him. Time after time I refused; the last time he reacted as if I had insulted him. But then he reconsidered and asked, “Is it maybe that you do not drink?”

That was precisely the excuse I had always offered to him and the group. He had not thought it was anything but an excuse until just that moment. Then he explained: Since the assumption was that everyone drank, the only explanation of my refusing to accept a drink from him or from the common stock of the group was that I had some private store of alcohol I was unwilling to share. When individuals or groups refuse to drink with each other, it is a sure sign of deadly enmity between them.

I am certain that many members of these groups would be called social drinkers if they were not homeless. Indeed, they might be called social drinkers more accurately than better-off people, because the drinking group was the only society I found on the street. People in better circumstances can find many associations and activities that do not involve alcohol. On the streets one must drink, or at least pretend to drink, to have any company or entertainment at all.

Of course, some of the people on the street who begin drinking socially in the drinking groups will become alcoholics—just as some people who attend cocktail parties will. But a businessman returning from a three-martini lunch who sees a drinking group on the street is likely to think that every member of the group is alcoholic. That is not so, and furthermore, I think that many of the people on the street who are alcoholic are so as a consequence of being homeless. That is, in many cases, homelessness comes first and alcoholism second.

I lied, of course, when I told the groups and the man who tried to befriend me that I do not drink. I will take a drink when the circumstances seem to me appropriate. On the street I seldom found the circumstances appropriate. I found survival on the street challenging enough with a clear head; I never understood how the heavy drinkers got by.

If I had a secure camp and I found a half bottle of a good wine or two or three beers in a Dumpster, I would take them to camp to have with dinner or just before I turned in. I always had a better use for whatever small amount of cash I might get than to spend it on alcohol. Needless to say, when I did find two or three beers in a Dumpster it was really only two or three and not upward of a dozen, which is what some people mean by “a couple of beers.”

I did find a considerable amount of liquor once—someone who was moving had discarded everything from a well-stocked bar, including a number of exotic liqueurs with unbroken seals. As it was late in a month, I called Billy and he gladly took the whole lot off my hands.

At one time I would have considered it hypocritical to refuse to drink with the groups on the street while I was willing to accept a rare cocktail in Sue’s or to have a couple of beers in camp. But I have come to think that keeping up appearances is not altogether a matter of deceit. I was not, after all, an alcoholic. It was no deception to refuse to appear to be one. Mostly I did not want to give Mr. Three-Martini-Lunch an excuse to think himself better than I.

Many in the groups did not drink much more than I, at least not at one sitting—although most of them did drink every day, as I did not. That they did not care how they appeared to a society that was otherwise indifferent seems entirely understandable. One of the yuppie excuses for not giving money to panhandlers is that the money might be spent on liquor. Surely the money would not be put to a better purpose if it were donated to an agency and used to make a payment on a social worker’s Volvo.

The truth is that the vices of the homeless do not much differ from the vices of the housed, but the homeless, unless they become saints, must pursue their vices in public.

Besides myself, I never knew a homeless person who would refuse marijuana. But I never saw more-addictive illicit drugs used by homeless people.

When I appeared in the university area, I was often approached by well-dressed students who wanted to buy “A” or “cid.” I assumed these were two new drugs, which like XTC had appeared after I stopped experimenting with them. When I denied knowing what the students were talking about, they sometimes accused me of being disingenuous. Well they might, for eventually I realized or I was told that “A” plus “cid” is “acid,” and I could be expected to know what LSD was. That the students were so bold in soliciting me for it led me to think that homeless people in the area supplied this drug.

When I met the drinking group in this area, I learned they did sell LSD, but my observations led me to believe that they sold LSD to raise money for wine and seldom or never used it themselves.

I gathered that those who used hard drugs usually were not homeless, but by trading in drugs themselves they usually had some accommodation, even if it were no more than a trashy shooting gallery. Of course, one can drink or even toke where shooting up would not be tolerated, so it is possible some people I met on the street concealed this activity from me, but I think I would have recognized the signs if that had happened often. Next to alcohol, illicit drugs were nothing among the homeless people I encountered.

As to myself, I am addicted to nicotine. The state asylum has adopted a smoke-free policy since I was compelled to resign. If I had been able to keep my job there, I am sure I would have lost it by now anyway for my dependence on tobacco. Nothing seems to go well unless I have caffeine. Like many other people in Austin, I suffer from seasonal allergies and for them I take pseudoephedrine or phenylpropanolamine. The combination of caffeine, pseudoephedrine, and phenylpropanolamine is sometimes sold on the street for speed, but other antihistamines send me right to sleep.

I sometimes saved drugs I found in Dumpsters, but most of these were antibiotics or things of that sort that might be of value to someone who had no access to medical care, but that have no recreational potential. I think it unconscionable that poor people in the United States cannot buy such drugs over the counter, as they do in most other countries. I understand that society may not wish to provide poor people with medical care, but to make it illegal for the poor to care for themselves can only be attributed to society’s spite or doctors’ greed.

I saved two kinds of opiates. As my leg began to bother me I saved Vicodin in hopes of relieving the pain enough that I could continue to make my Dumpster rounds, or to take for my migraines if I ran out of ibuprofen. I have mentioned that dysentery was frequently a problem, so I saved Lomotil or paregoric when I was lucky enough to find it—over-the-counter medications for this problem are utterly ineffective. Not many sleeping pills, minor tranquilizers, or diet pills appeared in the Dumpsters, but I passed by those that did. I did not care for such things for myself, and although I knew some of them had a street value—just as I knew some of the other things I found could be hocked—I never thought of trying to sell them, by which I do not mean I thought better of it, but that the idea never occurred to me.

I had been an attendant at the state asylum in Austin for seven years, five of which I worked in the admissions office, and before that I had worked in a walk-in crisis center. I could recognize most of the chronic lunatics in the Austin area and I met many of them on the streets. A few of them recognized me, but for want of the proper context they rarely knew where they had met me before.

Moreover after some ten years’ experience in the mental-health field, I could detect the symptoms of mental illness in many homeless people of whose histories I had no direct knowledge. The state asylum in Austin is a large institution that draws patients from a vast area. Often when patients are released they do not return whence they came. Austin is a liberal town and as good a place as any to be insane.

Most patients now are released from the state institution very quickly, but not because a rapid recovery has been effected.

In the 1970s a new strategy for dealing with the mentally ill was developed. It was thought that patients could be treated more efficiently, and more humanely, in their own communities. This seemed feasible because the most serious and the most common forms of mental illness responded well to drugs that were developed in the 1950s and the 1960s. The plan was to reduce the large central institutions and to establish many small clinics in the communities.

Whether this plan would have worked or not we will never know, for only half of it was implemented. The powers and resources of the central institutions were drastically reduced. But the community clinics were established in only a few places, and where they were established they were inadequate. Many communities did not want mental-health facilities right next door, although their being right next door, in touch with the neighborhoods, was a key aspect of the plan for the clinics. Breaking up the large institutions meant that economies of scale would have to be sacrificed, and neither the legislature nor the communities were willing to fund the clinics at a level that would have offered some chance for success.

To make matters worse, there were problems with the wonder drugs. They were so good in treating the disorders for which they were appropriate that they were often tried where they were inappropriate—in much the same way that penicillin was once prescribed for viral disorders against which it could not possibly be effective. If a little of the drug did not produce the desired result, physicians often increased the dosage. Inappropriate use of the drugs often ended badly. But even when the drugs were prescribed appropriately, they produced some undesirable side effects. Patients won the right to refuse to take the drugs. Patients who did not raise the issue of their rights often simply discontinued taking them.

Anyone who has had to take a medication for a chronic disorder will recognize the resentment one feels at having to do this thing that other people need not do. Mental patients feel this resentment as much as anyone, and they as much as anyone can deny they have the disorder and refuse to take the medication or can conveniently forget to take it. In addition, I have always suspected that it feels good to be a little bit crazy. At least one person has told me he tries to reduce his medication so that he can get the good feeling of being a little bit crazy. Unfortunately, just a little bit crazy is just crazy enough for him to believe he can do without the medication altogether, which he cannot.

I do not believe that patients who discontinue their medications often do so for fear of the side effects. But the side effects, though relatively minor, are real and are sometimes irreversible. A reasonable person might conclude that the risk of the side effects outweighed the benefits of the drug—or so thought the courts in deciding that mental patients ought to be able to refuse the drugs.

But the idea of the community clinics was that patients would take the drugs and would report to the clinics on an outpatient basis for minor adjustments of dosage and such. The clinics were supposed to have, at most, a few inpatients who would be stabilized quickly and returned to their homes, families, and neighborhoods.

When the plan went smash, the central institutions no longer had the capacity to handle large numbers of patients. As a result, subacute mental patients must be discharged to the streets until they are again sufficiently ill to be readmitted to the central institutions. Unfortunately there is no solution so simple as refunding the central institutions. Many of the evils of the central institutions persist; abusive and neglectful habits are still inculcated in the staffs of such institutions. But the power to compel treatment, whereby the central institutions occasionally and haphazardly did some good, is gone. Moreover, while acute psychosis is a vivid and unmistakable phenomenon that presents a need for hospitalization, even involuntary hospitalization, that few observers would deny, the more common symptoms of mental illness are matters of degree and definition that in the question of involuntary hospitalization try the limits of human wisdom and justice.

Matilda Temple was a crazy woman who occupied very much the same territory that Lizbeth and I frequented. She was from a well-to-do family in a large Texas city. She came to Austin not as a mental patient, but as a student. Many schizophrenic disorders first manifest themselves in late adolescence or early adulthood. And so it was with Matilda. Her illness was a great shock for the family, but at first they were very supportive. They put her in the best private institutions, and whenever she was released the family would set her up anew with a nice apartment and a vehicle. But Matilda would not take her medication. After so many cycles of treatment and relapse, the family washed their hands of her.

As an admissions attendant I saw Matilda many times. Most often she was brought to admissions by law-enforcement officers—then she would be floridly psychotic and violent. Rarely she appeared voluntarily, when the weather was especially cold or her food stamps had run out—then she was less violent but just as psychotic.

In my latter years at the hospital I worked on a women’s ward and had the opportunity of seeing Matilda when she was medicated. When medicated, she seemed as sane as anyone. She was an intelligent and strong-willed woman, with enough of a mean streak that it was clear to me that she was not drugged into a zombie-like state, but was for the nonce in her right mind. And she would say as much herself.

Of course, when I saw her on the streets again she was nuts. She talked nonsense constantly—anyone who has ridden a New York subway or the Hollywood bus in Los Angeles is likely to have heard this sort of talk, which mental-health workers call word salad. Fortunately, Matilda only rarely remembered that I had been her attendant, but it hardly mattered when she did, because she could not hold a thought for more than a few seconds. She usually carried a red sleeping bag with her and went from store to store begging for cigarettes.

Matilda slept on stoops and porches and sometimes on the pew at Ramblin’ Red’s—she got very upset with me when Lizbeth and I stayed too late on the pew. At night she screamed and shouted at imaginary people and monsters, and her threats to them were so graphic that she often alarmed people who did not know her.

Matilda received, at general delivery, an SSI check on the first of each month. Her allotment was not so generous as Dan Archer’s, but with it she might have got a small apartment, and in the apartment she might have received food stamps. But she disposed of her check quickly. Sometimes she literally threw money away. Other times she gave it away. She would get four large carry-out pizzas or a gross of doughnuts, eat a little, and leave the rest on the ground to be claimed by the fire ants. She was a crazy woman and she did crazy things with money. In any event, the money would be gone by the third.

I describe Matilda’s case in some detail because I know the most about it and because it is typical of the mental patients I encountered on the streets. (In particular, her sex is typical. In discussing alcohol I deliberately referred to men. I never saw a single woman in one of these groups. Very rarely a woman attended as the companion of a man in the group, and then she most often sat away from the circle. On the other hand, I seldom recognized insane men on the streets. A man as threatening and verbally abusive as Matilda would have been taken to jail. And I would guess some men kept themselves medicated with alcohol and camouflaged themselves among the drinking groups. Matilda sometimes drank a beer, but in general, the crazy women I saw did not drink. I cannot explain the difference.)

What should society do with Matilda?

By the time I saw her on the streets, she was no longer violent, although she could be threatening and verbally abusive. She had been through the state asylum so many times that they would not accept her as a voluntary patient. Yet, unless she was immediately dangerous to herself or others, she could not be committed involuntarily. When she was committed involuntarily she could be compelled to take her medication so long as she was violent, but precisely because the medications worked so well in her case she would cease to be violent almost as soon as she received her first dose. But then, because she would not take her medicine once she was allowed to refuse it, and her bed was needed for someone else, she would be discharged to the streets. She was obviously very unhappy on the streets, whereas when I had seen her medicated she had claimed to be quite content.

What may in justice be done for a person without his or her consent is a question treated in Platonic dialogues, yet for all the centuries passed since Socrates sought wisdom, it is a question I cannot answer.

Dr. Velasquez and Dr. Stalin did not mean to do me harm, but quite the contrary—or so I think when I am in a generous mood. Dr. Velasquez did not know whether I was mentally ill or not, and I do not think he believed he knew. What he did believe, that I know not to be so, was that the state asylum was a good place, that they would sort out my disorder if I had one, and that I would be better off for going there. He may also have known that by committing me to the state asylum, he could assure that the state would pay the costs of the treatment of my phlebitis. At any rate, I do not think he was wise enough to decide for me, and so I do not think I am wise enough to decide for Matilda.

I have heard psychiatrists say that anyone who is homeless is ipso facto a chronic schizophrenic unless there is some more evident diagnosis. By one school of thought it is a form of mental illness to be so much at variance with the commonly accepted values of one’s society, and it was to this school the Soviets applied when they committed their political dissidents to mental institutions. By the criteria of homelessness and deviance, I was no doubt mentally ill.

But given my values I thought I was about as rational and consistent as anyone could claim to be. I was moody. But in my material situation I think it no wonder that I was sometimes depressed. The wonder was that much of the time I managed to buoy up my spirits.

On the streets, one day very quickly blurs into the rest, and without the checkpoints of ordinary conversation I sometimes found my mind had wandered far from the path of sound judgment. I counted myself as sane as I could be in my circumstances, but I am in no position to argue if this account leads anyone to another conclusion.