Lessons From the Street Through a Homeless Youth With Depression
I (J.M.) am squeezing his deltoid, bracing it, for the impending infiltration of a month’s worth of aripiprazole. He stares back at me with trust, and likely fear, from the passenger seat of his case worker’s car. I can’t help but feel the pain of hope as I think back, knowing the odds are not in his favor. It has been several months since we first met at the outreach center for homeless youths that he has frequented since his adolescence. Although I never knew him as a minor, this is somehow the first time I see him fully as an adult.
Nine years old—that’s when he first experienced homelessness. He made a choice then to escape the brutality of his father. He knew he wouldn’t be missed at home, and his plan was simple, yet brilliant: stay at school for as long as possible, then sneak onto the roof after everyone had exited the property and sleep nestled high above the classrooms he attended. I sat listening, stunned. As a psychiatry resident I am accustomed to hearing about the shocking circumstances my patients endure; however, I simply cannot fathom being on the streets, alone, at such a young age.
To my surprise, my institution’s electronic medical record captured a glimpse of him as a child. The school-based psychiatry encounters began at age 8. Shortly after initially being seen for the evaluation and management of attention-deficit hyperactivity disorder, he began to exhibit new behaviors, such as hoarding food, urinating outside, and leaving his home for prolonged periods. I feel my stomach turn as I read the signs that an elementary school child had begun to transition to living life outdoors. In retrospect, the clues were evident. The providers then were suspicious; his home was without doubt chaotic, but what could they do when both the family and the patient continuously rejected the providers’ concerns?
With puberty, life became more complicated. It is easier to survive with a family, or at least a substitute one. In his case, it was a gang. Because this family was brutal, too, he left again. He found support at the local youth outreach center where I first began to see him. The case managers at the center had known him for several years before our first encounter, and they remarked on his innate ability to bring joy into a room. Immediately, I understand how the staff who have worked with him feel as I watch this young man voluntarily clearing the debris, long hidden, from under the cushions of the outreach center couch. He smiles and laughs as he cleans, simply because this is the only true home he has ever known, and he wants to give it the care it deserves.
Once alone in my office, he shifts and discusses his past, his present, and his lack of hopefulness regarding the future. How can such a facade of joy be maintained in the face of such profound depression? I can’t help but ask. He doesn’t know what it feels like to be happy, but it looks nice when other people feel that way, so why not allow them the luxury of experiencing joy, an emotion which has been so foreign to him, he reasons. He is puzzling to me, with his exuberant demeanor but depressed content, which persists despite obtaining an apartment.
In the safety of our appointments he begins each session by asking me questions. Before he answers my onslaught of inquiries about his mood, safety, and medications, he wants to know how my week has been. Initially, his insistence that I provide a genuine answer to this question is unsettling. My acute awareness of the tenuous nature of our doctor-patient relationship and the ever-present need for the firmness of limits when working with this population is forefront in my mind during these periods of inquisition. Especially because the common thread among my young patients without homes is a history of authority figures violating the most essential of boundaries. Often, when this experience inevitably arises, the conversation is deflected to discussions of popular movies or music, which he downloads as pirated copies off the Internet. His posited questions can at times be more difficult, however. After discussing his life and how he came to be the young man he is today, he asks if I have ever endured the types of tragedy he has faced. A lump solidifies in my throat; breaking the fragile rapport we had developed over polite but safe conversations regarding popular culture was not on my agenda for our visit. I answer honestly: no, I haven’t. Instead of attempting to relate to his experiences, I acknowledge that I simply can’t. I do not know what it’s like to be part of a minority population living on the streets because of unfathomable abuses experienced at home. He does not demand shared experiences. That is not his expectation. Rather, he is in search of empathy and honesty, and our rapport strengthens. I realize he needs to know that the expression of these feelings is safe—that I can be vulnerable during our sessions as well.
The eviction from his new apartment several months later crushed his ability to uphold the facade he had used for so long. He had been relieved from the burden of sleeping on the street for only a couple of months before being told he was to return to the desolate alleys and parking lots he had escaped. He was crumbling, and I had no choice but to commit him involuntarily to the inpatient psychiatric setting by that afternoon. His chronic loathing of life had pivoted into a certainty of action that left no other option. Yet, our relationship remained unblemished somehow by his commitment to the inpatient setting, and I visited him daily over the next several weeks of his admission. He returned to the streets shortly after leaving the hospital. The disposition plan fell through before I could even see him for his follow-up appointment less than a week after his discharge.
At this point, the appointments become laced with a tinge of fear, my fear. How can I ever keep a chronically suicidal man safe on the streets? How can I help him overcome the hopelessness that has ensued from countless years of being victimized? The weight of my inability is crushing. I feel helpless. The truth is I can’t save him from the perils of a life lived outdoors. I cannot control how cold it gets outside. I cannot control whether he is assaulted on the street. I cannot control whether he is arrested for the petty crimes of homelessness. Sitting in the discomfort of my own safe distance, I am overcome by the sense of unpredictability that has been with him for most of his life. My powerlessness to reverse prior atrocities or prevent future traumas in his life is reminiscent of the sheer pandemonium of his early life. This is a feeling I am not used to having. In my life of comfort, predictability, and convenience, I have been sheltered from the uncertainty he faces daily. My small taste of his daily chaos is unsettling.
The truth is I do not have capacity to comprehend the horrors he has endured. Unfortunately, although his story is extreme, there are many more like him at the outreach center where he and I met. I often worry, sometimes cry, and deeply care for the homeless youths I encounter each week. Creating and implementing a psychiatric clinic for this population has been my dream for years. Through the help of mentors, as well as quite a bit of grit and determination, I established my clinic while in residency. It is simply what lights my soul on fire.
Yet, at times I have agonizing feelings of self-doubt. Am I able to sustain providing care for an unbelievably traumatized population? Will I be crushed by the weight of the secondary trauma caused by hearing their autobiographical accounts? In my uncertainty I seek the counsel of both trusted mentors and my personal therapist. Having this support rejuvenates and restores me to keep pursuing the creation of specialized systems of care for the population that I have chosen to serve.
Sitting in the case worker’s car with this youth, acknowledging my own helplessness, I am granted an unexpected relief. I cannot ever take away the traumatic events of years past. I realize I have no magic wand to wield and relieve him of the burden of sleeping on concrete. My contribution to the alleviation of his suffering is being one of the few people he has ever encountered who has cared for him without contingency or ulterior motives. Freeing myself from the burden of undoing the past or altering the future of my young patient’s experiences in homelessness is alleviating. I am no savior. Rather, I strive to be an advocate, a means of equipping and empowering young people facing immense odds to have the lives they desire. I encourage them to have the lives they want for themselves, not the lives that I want for them.
All these moments flash before my eyes as the syringe empties, and I can’t believe we are here, now. As his impression lingers on my consciousness, I realize he is marked not by his trauma but by his resilience. He leaves the street psychiatry appointment to return to the cold of February. The full-time job he works hasn’t resulted in a stable place to rest. I am unsure if it ever will; however, I am sure the impact made on each of our lives is mutual. We part ways, taking different paths but ever thankful that they intersect.
