I had clients that were homeless with schizophrenia, and it was a challenge like I’ve never had before.
One of the more interesting aspects about doing mental health work in a community setting is that oftentimes you see the most raw or extreme cases of stuff you either only read about in books or saw portrayals of in movies.
Schizophrenia is one of those disorders that, according to a client I had, “you don’t know you’re in it until you’re in it.”
While I’ve never been diagnosed with schizophrenia or knew of a family member that was, case managing homeless clients with schizophrenia in the community definitely made me feel like I was in it.
My job at the time was to find potential clients that were homeless (or at risk of being homeless) and diagnosed with a severe mental health disorder. Clients in this category often have no active support network because an under-treated diagnosis can cause that network to crumble. Even worse is when your support network has limited resources and doesn’t know how to help.
Homeless clients with schizophrenia often had the worst symptoms in my cases. The untreated symptoms are so prevalent that people are instantly fearful of potentially life threatening situations, and with good cause.
How Schizophrenia Looks
It would probably take 20 more blog posts to describe the everything you need to know about Schizophrenia and schizo-type disorders. One blog post doesn’t do it justice, but Schizophrenia is a thought disorder where the brain doesn’t see the world the same as everyone else. Schizophrenics can suffer from what we call “positive’ or “negative’ symptoms. Positive ones are active and engaging, like auditory hallucinations, delusions, or disorganized speech. “Negative” symptoms include lack of emotional expression.
All of those things , especially the hallucinations, seem real to the patient. Words can be pictures. Imaginary and convoluted ideas are concrete and real. What makes sense to you is alarming and dangerous to all around you and you don’t know why. There’s no cure for it, and the best home someone can have is to keep symptoms down. The hallucinations lead to another symptom: psychosis, where the patient has harmful or dangerous thoughts. The first “psychotic break” that indicates schizophrenia is often the scariest. Most often it’s the early 20s for males; mid-20s for females and once again in the 40s. That’s when the patient’s delusions or hallucinations come to a head and he or she gets into a situation of harming himself or others. To the outside world, it can look like someone on drugs like meth or PCP.
How I Met My Schizophrenic Clients
I’m not a doctor and I didn’t work in a hospital setting, so the “patients” I saw were “clients”. They also qualified as clients because they had every right to agree or disagree to services. The only exception was any client that had been conserved, i.e., had their decision-making legal rights removed. I only had one such client. All others decided on their own if they wanted help.
So imagine this: someone homeless with schizophrenia, who likely didn’t have very good past hospitalization or mental health services experiences, meets me and I explain what I have to offer. I’m up against walls of paranoia, someone who speaks in sentences that don’t make any sense yet has just enough decision-making power to get through society without being institutionalized. How does someone like me say “sure, I can get you meds and a place to sleep in a generally safe setting. Just sign here!”
Remarkably, with a lot of help, I did. Some clients did have family members that were very estranged but caring. For schizophrenics, that relationship-as loosely tied as it was- looked like the only lifeline to the “normal” world. Some clients also had a time where they had the right treatment and functioned well until abandoned or not properly cared for. The period of no treatment went on too long and they went “underground”.
Abandoned On The Street: Shelly
Names and some details have been changed to protect privacy.
Shelly’s case was one of the more heartbreaking cases I ever had. She was staying at a local shelter when I got the referral.
“How is she presenting?” I asked Marlaina, a former coworker who was now employed by another organization. She had bypassed all normal protocols for the referral process and dialed me directly.
“ I can’t say for sure what her diagnosis is because she doesn’t have many records on file. Where she claims she was living at before getting dumped has all the information, and they aren’t releasing it. But…you’ll understand why you need to help her once you have a conversation.”
That was often a complication when meeting potential clients off the street. Many have had treatment in local or regional mental health centers, but if they were incredibly symptomatic they would become what we called “poor historians.” You had to start from the ground up and do some entry level detective work just to get a sense of direction.
The way Shelly presented made it tough. She wasn’t combative or hard to understand. Shelly had the kindest demeanor. She was always happy to see you and felt like it had been a very long time (even if it was just two days). If you asked Shelly what she had for breakfast, she could tell you. Ask her about what medications she had been on, she will give you the scientific name and the dosage.
But ask her how old she was and you’d get an interesting answer. “My birth certificate says 62,” she’d start. “But the other lady that lives in my brain is actually 2,000 years old. And that’s how old I really am. That’s what she tells me.”
The lady she is referring to is Francis, a former movie star that has controlled her life for a long time.
“She kept sending me to places where I’d get tortured and it wasn’t fair because I didn’t do anything.”
Ask Shelly about her family and she’d name off relatives that, when verified off the Internet, could be found.
But there were some she didn’t talk about much, like the ones who left her in this predicament.
Shelly used to be permanently institutionalized in a city less than an hour away. The facility she stayed at was “wonderful” to her. She was clothed, fed, had friends, took her medications, watched TV and had a good time living there.
Then one day a relative came by and started the process of having her removed. They promised that they had adequate housing and would take care of her. The state would authorize it, along with the support money that would be due to them for care, which was close to $1,000 a month.
They were approved and signed Shelly out. The drove her down an hour and had her living in a semi-rural community at their house. But over time, Shelly says “they weren’t caring for me. I was caring for them.” She didn’t know how to use a phone and would easily get lost, so they had Shelly stay home and clean. She sometimes cooked for the relatives, who barely supported her needs. Shelly was on a special diet and they didn’t really attend to it.
And then one day they dropped Shelly off in town. She didn’t know how to get back home. When someone found her old house, it had been repossessed. The relatives left town.
So Shelly wandered the streets, homeless with schizophrenia, unmedicated, barely clothed, and often checking into a crisis center that would support her when they could. They eventually contacted the local shelter, who also wasn’t equipped to help with her mental health care but knew people who could, such as my former coworker Marlaina.
And by the time I got Marlaina’s call, it had been nine months since Shelly had been removed from the institution, brought “home”, and then dumped on the street. She had only been in the shelter for a month.
Working with Shelly was fairly easy compared to doing work with other schizophrenic clients. She didn’t mind going to doctor’s appointments. Her delusions didn’t spark any adverse actions. They were mostly imaginary stories of her past and the voice of the 2,000 year old actress in her head. We were able to get her back on medications that she was willing to try. We got her a new picture ID. We started the lengthy process of getting her supportive funds back on track to her own account.
What we couldn’t do was get her out of the shelter and into supportive housing.
I took her to one location that was perfect. The owner was a nurse by profession. The support staff and other residence all had disorders that were manageable. They didn’t require much of the clients other than basic chores. And it was full of beautiful furniture. Shelly seemed to take a liking to it while we were there and while she was interviewed.
But on the ride back, Shelly seemed antsy. “I don’t know, Paul,” she started. “They seem to want a lot of work.” I told her that the chores were the same as what she was already doing.
Shelly agreed. She seemed to be searching for the right words.
“I’m really sorry. I really am, Paul. I don’t want to be difficult, but…I just don’t wanna be somewhere that’s gonna foreclose on me.”
That wasn’t a delusion. It was her way of communicating a real fear based on a real past event.
“I wish I could just go back to the institution. Those places don’t close.”
Near Death Experiences And Ice Cream
One of my first clients, Dante, was diagnosed with Schizoaffective Disorder. This is a combination of mood disorder (like Bipolar or Depression) and thought disorder. He often heard negative voices and couldn’t get over past guilt from choices he made. As hard as he tried, it was like a bad tape of Dante’s mistakes on repeat in his brain when everything was quiet. His mood was usually depressed and when he wasn’t sure how a decision was going to end, sometimes he’d call 911 and say he was going to kill himself even though he was just lying in a bed, doing nothing. Other times he would make up stories about people in the house trying to hurt him. Dante didn’t have the severe delusions or incoherent speech; he was very well-spoken. Those weren’t delusions, but that was his way of coping with the ambivalence of not wanting to be somewhere yet not feeling unsafe. He’d tell me he wanted to move out of a place I found safe for him. But if I asked him why, he wouldn’t have an answer and just say “I don’t know why I keep saying I want to move. There’s nowhere else I want to go.”
One day, when he had stopped taking his antidepressants, he said he wanted to move. We were driving back to the house after getting him some ice cream (his favorite reason to leave the house). I went through the same line of questioning. He didn’t get upset but started rambling about “I just need to leave the car” and slowly undid his seat belt. I asked him to buckle it back on. He did, but then went for the door handle. I hit the automatic locking button on my side of the car. Fortunately Dante was slow in movement and I was always three seconds ahead.
At least that’s what I thought, because I didn’t expect him to grab my steering wheel while we were on the highway.
It was also fortunate I was much stronger than him. I kept the wheel straight enough to pull over and warn him. “If you decide to off yourself, that’s not what I want. But if you do, don’t take me with you.”
“I’m sorry,” he said.
The next week he attempted it again. I told him from that point on I would still work with him, but unless he stayed on his treatment plan, we were no longer going on ice cream trips together and he would need new ways to his appointments. If he didn’t make his appointments, there was a chance he would lose his housing. Dante apologized again but said he understood. I would come by for appointments and he’d ask me to take him for ice cream. I’d remind him why I couldn’t do it.
“Oh, yeah. That steering wheel thing.”
After three months of being on riding “time out”, the house reported he was back on his medications. So I slowly integrated him back into the recreational excursions, first by having him sit in the back seat. Eventually he earned enough trust to be up front again.
We didn’t have any transportation problems after that.
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