by Jason Albertson, LCSW
A recent article in the Times Review, by Dr. Peter Kramer, psychiatrist and author of Listening to Prozac, highlights the value of the narratives our patients tell us, both for clinical purposes and to provide recovery value to others who may encounter the narrative or vignette. It is in that vein that I present this narrative of outreach to one of the Tenderloin Top 10, a group of homeless individuals whom the Tenderloin Police identified as their most problematic in terms of street dwelling, public intoxication, and anti-social behavior. Outreach to them commenced after a street shooting in which 10 bullets were fired, wounding nine individuals, leading to a review of safety needs in the area, and a request that Department of Public Health make outreach to this area a priority.
We first met Mr. Z.Z. at Eddy and Taylor, ground zero for crack cocaine and street crime. He was sitting astride a child’s bike when I walked up to him and introduced myself. Foot traffic flowed around us; people cleaned crack pipes and looked at us suspiciously. Wearing a City badged vest, carrying an obvious two-way radio I represented authority, perhaps police, an ambiguously situated worker in the urban context. My introduction is intended to defuse: “Department of Public Health, Homeless Outreach Team,” I always say. “Health and Wellness outreach. Can we talk?” That usually does it.
Z.Z. and I talked. I let him know that SFPD was concerned about him, that we wanted to help him to a place of greater stability so that he didn’t have to be out on “these hard streets” as I put it, getting tickets. He was reluctant to engage, limited his answers to monosyllables, but eventually was able to talk with me in some detail about how long he’d been in SF, where he’d come from, what kind of work he’d done, and whether he had any outstanding medical issues. He had poor dentition, the result of bad diet, no toothbrush, and a long time lived on the street. He looked thin. He had no government benefits, supported himself by eating at soup kitchens, wasn’t interested in treatment, and felt he could not stay in a shelter. “Too many people, man, and I used to be The Man, but I don’t do it no more.” He means he used to sell drugs. I asked him to come into Tom Waddell Health Clinic so we could do a TB test, get him eligible for shelter, and make a plan for care. He agreed he would come in on Friday, but didn’t.
Two weeks later, my phone rings at 7:15 a.m. It’s SFPD Officer John Law, one of the Tenderloin Outreach police officers who developed the Top 10 list. He tells me that Z.Z. approached him on the street and wanted to meet with me. I tell him we can meet him tomorrow, outside the police station at our regularly scheduled outreach time.
At the police station, I recognize Z.Z.. He seems thinner than on our previous encounter, and I invite him to the waiting area inside the police station where we talk. He tells me that he feels he is ready for care; that he has been abstinent from crack cocaine for the past two weeks; that he will “do whatever it takes” to engage with SFHOT with the goal of having housing. He hasn’t had a place to live for 15 years, and he is tired, he says. “I can’t do it no more.” Fortunately, on this day, I have a bed at a social model detox operated by our partner, HealthRight 360. These beds are set aside for this outreach. Having them makes it possible to provide treatment on demand.
I discuss the possibility of entering into treatment with Z.Z. He tells me he has been taking cocaine since it was introduced in crack form—since the mid 1980s. He shakes his head at the length of his time with the drug, says, “I’ll do anything. I flagged the law man down to get him to get me to you.”
He looks at me, says, “You tell me what to do. If you think I need it, I’ll do it.” He has tears coming from his eyes. He turns away. I tell him that I can’t make this decision for him. The moment tempts me to make the decision for him. Put him in detox. It’s a better option than shelter, leads to other treatment (he’s got a long history and relapse potential is high)—but then the other side of the arguments intrude. The ones about autonomy, how it is better to let people choose their own course and then review with them the outcome of the decisions they make. If I make the choice for him and he’s not invested, it won’t work. And if I make the choice for him, he will be angry and resentful toward me and the program if it doesn’t work, increasing his relapse risk.
“People need to have the consequences of their choices” writes Dr. Mark Ragins, a psychiatrist who provides care to people in Long Beach with mental illnesses and substance. It is the way learning happens, the hard, uncomfortable learning that our better selves wish we didn’t have to watch people go through over and over.
He makes his own decision. We build a plan: shelter reservation at the low-volume, kinder, gentler facility for a week. I give him an appointment to come and see me here at the clinic and a homework to go to the wellness center for orientation and as he does, to specifically think about his thoughts and feelings as he goes through orientation. He agrees.
On the walk back through the Tenderloin, I can’t stop thinking about how he gave me the gift of his tears. A streetwise man who trusted an unknown-to-him outreach worker enough to cry in front him.
At the office, I sit with our volunteer doctor and our AmeriCorps volunteer, and discuss the temptation to do the right thing for the wrong reasons, and how that can be the final treason. But I’m not thinking about Mr. Z at the time.
I’d thought about this as an interesting matter that has clinical significance in the context of Buddhist ideas about intervention, respect for all living things and how it highlights the tension between supporting someone to have the life they want versus the life they need to have for the time being.
It’s only an hour after they leave that I recognize the relevance to the current situation. Stuff bubbles up from somewhere and it can be hard to recognize relevance, even when it slaps you in the face. Chalk one up to outreach that features active engagement and listening.
More than five months later, Mr. Z. continues in sobriety and on our service today. He has some weight on him now, notes he has gained 12 pounds since we placed him in shelter. He is beginning to refer other people to us. We were able to get him a crowd-sourced ride home on a bus, to reunite with his family that he left 24 years ago. His son who was three months old when he left is now 23. He has a grandson. His nephew is a medical doctor, serving in the armed forces at Fort Bragg. He spent New Year’s with his brother’s family in Houston. He continues to stay in a shelter and plans to return to Houston for good after his SSI disability case is heard, a case that we assisted him in filing. He has severe cervical spinal stenosis, with constant pain, numbness, and tingling in his extremities. He cannot talk to me without tears, but sometimes they are tears of joy when he describes how good it was to be with his family during the holiday. It is not clear to me—and perhaps not to him—why he had to leave Houston those many years ago, why he left and got swallowed up in the Tenderloin realm, in the world of smoke. But it is clear to me that by not making the decision for him, by not yielding to the temptation to be a patriarchal protector—an interventionist if you will—we did the right thing. And so did he.