Would they be better off in a home? Why do people become homeless?

National Review, March 5, 1990 by Laurence Schiff

Why do people become homeless? Reagan's cuts, say liberals.

Throwing the mentally ill on to the streets, say some conservatives.

But there were no cuts and only a few homeless are mentally ill.

The rest are homeless because it beats the alternative.

IT IS GENERALLY believed that our cities are peopled by a vast and growing army of homeless men and women, on the streets because of a lack of compassion (read: the dismantling of the Great Society by the Reagan Administration). Yet in fact, the welfare apparatus remains largely intact. Marginal reductions in its exponential growth at the federal level have mostly been compensated for by states and municipalities.

Why, then, is homelessness one of the few growth industries in the United States today? First, it is subsidized through a self-serving mental-health system which promotes the myth that a huge percentage of the homeless are mentally ill. Second, it is continually encouraged by the government, directly through transfer payments, and indirectly through antipathy to the free market system.

The actual number of homeless men, women, and children in the United States remains a subject of considerable dispute. Estimates range from a low of 250,000 to a high of three million; my own estimate, admittedly an educated guess, is in the range of 750,000 to one million. But a prior problem is that there exists no clear definition of a homeless person. Significant numbers of people who have not spent even one night sleeping on the street are nonetheless counted in the homeless population. Some have lived in the same shelter for years; some live in welfare hotels, undeniably uncomfortable but housing of a sort; and some are periodically thrown out of their homes because of anti-social behavior (such as drug abuse) that their family or friends find intolerable. Thus many of the homeless are not homeless at all in the usual sense of the term. But do they choose forms of accommodation which most of us would shrink from in horror because, as another widely held belief has it, they are mentally ill? Over the past two years, there have been at least four large-scale studies of the extent of mental illness among the homeless, all of which (two in New York, one in Los Angeles, and one in, of all places, Melbourne, Australia) have come up with a remarkably similar prevalence rate of around 70 per cent. But how are such estimates arrived at?

Since 1952, psychiatric diagnosis has been systematized via a published set of criteria called the Diagnostic and Statistical Manual of Mental Disorders. The present manual, DSM-IIIR, is divided into what are called five axes. Axis 1, for instance, encompasses "major mental disorders," including the schizophrenic, bipolar formerly manic-depressive), and organic disorders. However, it also includes impulse-control disorders, psychosomatic disorders, alcohol and substance abuse, sleep disorders, sexual disorders, anxiety and mood disorders, and so on. (Believe it or not, nicotine dependence is classified on this axis, although, to be sure, that is a controversial diagnosis, and rarely used.)

CLEARLY, THEN, the definition of what constitutes mental pathology can be made so broad (particularly by the inclusion of Axis II, or personality disorders) that were one to use DSM-IIIR to diagnose the population of, say, Scarsdale, one might come up with a figure of, oh ... 70 per cent-though a few wags have suggested the percentage in Searsdale is probably higher. But much more is involved. The budget for the coming year in the mental-health field, as in any public agency, is predicated upon the expenditure of all moneys for the present year. Thus there is enormous pressure to "give" a patient a diagnosis. Several of the Axis I diagnoses are used as a sort of catch-all to justify admission to a program. So, for example, someone who is basically nasty or aggressive is no longer just nasty or aggressive, he's an Intermittent Explosive Disorder (DSM 312.34). Similarly, drug addicts have a way of becoming Dysthymic Disorders (DSM 300.40-"a chronic mood disorder, also called Depressive Neurosis") in order to let them be detoxified at general-hospital psychiatric units, since insurance companies won't always pay for those who are merely drug addicts. About the only diagnosis I've rarely seen employed is No Pathology (DSM V71.09).

Another problem is inherent in the current structure of the public mental-health system-i.e., municipal or state hospital facilities-which is where most of the "homeless" are diagnosed. The vast majority of the psychiatrists in the system are from foreign countries, predominantly India, the Philippines, and Korea. Very few have much familiarity with American culture, particularly ghetto culture, and many barely speak English. And contrary to the idealized conception of the analytic session, psychiatrists in public facilities spend little time with any individual patient (they are precluded in any case from the classical 45-minute session by the huge caseloads-sixty to 120 patients). Indeed, one of the attractions of the state system for a foreign physician is the secure salary and the lack of intimate patient contact. When I worked at a large state hospital in the early 1980s I sensed considerable resentment at myself, an American, intruding on their "turf."