It was 1990 in Brooklyn, N.Y. when I was hired as a treatment coordinator at a facility for adolescent and adult drug addicts. The crack epidemic was ravaging communities on a national scale and AIDS was a global health crisis. I had just completed post-graduate work at Coney Island Hospital, where I was employed in a detox unit and a partial hospitalization drug treatment program. It was in equal measure inspiring and heartbreaking.
Many of my clients were victims of sex trafficking, mandated through the criminal justice system and child welfare services. A vast majority were IV heroin addicts if they were not also hooked on crack. Needless to say, they all presented with horrendous traumatic histories.
Thankfully, prior to the inception of managed healthcare (Clinton, 1993), resources and healthcare were far more abundant for indigent addicts. The men and women I treated were afforded the opportunity to receive full disability benefits while undergoing a comprehensive, hospital-based five-day a week, morning to late afternoon program, inclusive of group, individual therapy, detox, vocational counseling, creative arts therapy and psychiatric services.
For those who attained full sobriety blessings were reaped, but often their good fortune was short-lived due to the blight of the virus. When after three years I decided to venture into a managerial position, leaving the staff I worked with and the men and women who entrusted me with their lives was rife with joy and sorrow. It was difficult saying goodbye.
The personal growth I acquired along with what I learned clinically, accompanied me when I began my new position at a community-based program. It was there I was challenged to collaboratively design with educators and counselors a viable treatment structure for adolescent and adult addicts. First and foremost, as my previous position taught me, it was vital to create a therapeutic culture in which safety and stability prevailed. Before all else, that element was critical to establishing a trajectory of healing and growth.
Unfortunately what I walked into was a shit show.
There was no operable treatment structure in place, no drug testing, no morale. Adult and adolescent clients were actively getting high. Those enrolled in the alternative high school rarely showed up for class and when they did, they were dangerously oppositional. The ‘family component’ was comprised of participants frothing at the mouth to berate their children. Consequently, teachers were legitimately irate. Likewise, counseling staff were burnt out from custodial maintenance. The environment was a toxic, hostile, chaotic breeding ground for pathology.
Establishing safety and stability was possible, but it would not be easy.
Being reasonably free from harm is a fundamental provision for a satisfying life. It is also a critical pre-requisite to healing.
According to humanistic psychologist Abraham Maslow (A Theory of Human Motivation, 1943) physiological needs (air, food, warmth, clothing, shelter, rest) and needs for safety (security, employment, health, protection, familial morality) precede the attainment of love and belonging. Accordingly, for a sturdy reparative bond between a client and therapist to form the essential needs for safety and stability must be satisfied. Within the context of a comprehensive mental health agency, this means the treatment culture needs to uphold internal and external conditions that promote a baseline of community support and well-being.
Hence, cultivating a therapeutic culture in an environment besieged by dysfunction required the development and enforcement of clear treatment policies and procedures that would ensure steadfast protection and guidance. Operating from the premise that a clear procedural structure would provide safety and stability meant informing clients that ongoing engagement in treatment required consistent attendance, demonstrating a commitment to sobriety as evidenced by the results of routine drug screenings and adhering to the requirements of probation, parole and New York’s Administration of Children’s Services (ACS).
Likewise, the weekly family gripe session was to become a place where systemic abuse, mental illness and addiction would be processed. Additionally, parents struggling with addictive disorders would be encouraged to participate in the adult component of the treatment program.
If these conditions were not met, discharge would result. Naturally, this did not go over well.
The proposed changes signified a disruption of the family ecosystem. By examining roles and difficulties the homeostasis (Bateson Project) or balance would shift. Abiding by shared accountability would effectively dismantle the adolescent addict’s scapegoat identity and allow for an assessment of familial and generational patterns. As to be expected, rather than turn the attention on themselves, many of the parents simply pulled their kids from the program.
Similarly, challenging an addiction rouses combative defensive posturing. Hence, select clients in the adult component of the agency either disappeared or launched a micro revolt. Along with the mass exodus were vitriolic group dynamics, as non-compliance with treatment requirements were finally being met with consequences.
Clients who remained were dissuaded from deep diving into complex and acute traumas before establishing sufficient sobriety and ego strength. Although this established pattern consistently ignited traumatic flooding and dissociation which in turn triggered repetitive relapse, we had yet to prove that by fostering internal and external secure, supportive conditions the eventual processing of psychological underpinnings could be responsibly managed.
Indeed riding out the initial stage of dissent was grueling, but also auspicious. Those born into dangerous circumstances cannot easily attain the luxuries of safety and stability. Catastrophic expectations and anticipatory anxiety infiltrate a nihilistic worldview in folks beset by addiction and complex trauma. Naturally, it took a while to trust that enforced standards and life-affirming norms would ensure a protective, stable foundation that would galvanize a robust therapeutic culture of fellowship and recovery. However, once certainty took hold deeper excavation and transformative possibilities did indeed ensue.
Approaching the process of constructively reframing a history of systemic traumatization so that the past can be mourned and parsed out from the present (i.e.- complicated bereavement), irrespective of whether it occurs in an agency or private practice setting, necessitates a foundation of basic tools and resources that foster safety, regulation and containment.
Once physiological and a modicum of emotional needs are met, having one’s suffering understood and believed by a trusted witness can be received. Only then can the urgent longing for integration be potentially realized. My personal story attests to that truth.
There was no way I could embark on repairing a self that was insubstantial and broken when I was living with my schizophrenic mother in a dangerous welfare building, whilst getting stoned every day. At 17 years old, if I was to survive I had to move out, get a job(s) and commence with enrolling in a city college. With those provisions in place, I could then pursue treatment. This was a terrifying task.
Without adequate shelter in place and a meaningful structure comprised of work and academic pursuits (thanks to Pell Grants and TAP), I never would have had the ego strength to participate in therapy. Even with those basic necessities in place, I felt so worthless and undeserving that I could barely tolerate my therapist’s steadfast and principled emotional investment and empathic stance. If my basic needs for a stable home environment and a supportive academic community and employment were not available to me, I would not have been able to rely on therapy to help me face the profound level of despair that would have shattered me in childhood.
Without ongoing treatment I could not reevaluate my identity as a ‘bad’ person, stabilize addictions, and feel worthy of relationships that allowed for authenticity and nourishment. Nor could I rebuild a life characterized by possibility and hope.
Without a doubt, managing the traumas of loneliness, marginalization, addictions, stigma, dissociation, flooding, and rage necessitates external and internal resources that afford sufficient safety and stability so that treatment can be utilized. Yet current federal policies referred to as Housing First focus solely on housing as the panacea for the homeless mentally ill.
Accordingly, abstinence from drugs and alcohol, or even participation in substance abuse treatment or mental health services is not woven into this model. As evidenced by the public homeless encampments and street disorder infiltrating the American landscape, Housing First is an abysmal failure.
It does not work because housing devoid of provisions for treatment and treatment that is devoid of provisions for physiological needs (such as shelter) is a dead end. Internal safety and stability cannot be attained through shelter alone. Allocating treatment reforms for substance abuse disorders, mental health disorders, and physical health conditions plaguing those who are unsheltered is crucial to reducing homelessness and ensuring sustainable healthcare.
Regrettably, with an unsustainable broken health care system and an absence of universal healthcare coverage in the mix and a complementary emphasis on digitizing healthcare, the prognosis for America’s mentally ill homeless and indigent population is frighteningly poor.
Unless we remove the barriers imposed by corporatized healthcare and return to prioritizing fundamental essentials such as community outreach, case management, supervised housing, nutritional and medical assessments, and vocational rehab concomitant to comprehensive mental health services, the needs of the indigent mentally ill will continue to be ignored and justified with neoliberal euphemisms touting the right to exercise an alternate lifestyle. This sort of buzzword rhetoric mitigates capitalism’s moral failure. Worst of all it enables violent crime, rationalizes away untreated mental illness and glorifies addiction.
If “the true measure of any society can be found in how it treats its most vulnerable members” (Gandhi), given the present state of our siloed health system and abysmal regulatory policies it is jarring to consider how much we have fallen short of a basic measure of decency.