Ed Durgan: Lessons from Vancouver in homelessness and mental illness

This past fall, after eight years at UBC, I finished an interdisciplinary PhD on homelessness and mental illness in urban environments. I was mainly interested in comprehensive solutions. I had advisors in architecture, philosophy, and psychiatry. It is well established that the prevalence and severity of mental disease is greater in urban environments than anywhere else and there is little agreement on the reasons for this. I went to one of the epicentres of the crisis, the Downtown Eastside, to try and figure it out. My study benefitted from collaboration with the Downtown Eastside Residents Association and the Vancouver Area Network of Drug Users.

Besides studying the histories and current state of the arts in psychiatry, asylum architecture, and social housing, I had 12 severely mentally ill research participants living in a variety of impoverished dwellings in the DTES. Those participants fit diagnostic criteria for a wide range of mental disease. I recorded interviews and analyzed them with qualitative research methods. I found many themes, but focused on these five: distressed personal time, homemaking, management of mental health, contingencies of being poor in the DTES, and fundamental human rights.

Distressed personal time: Homelessness, mental illness, addiction, and poverty have at least this in common. Participants struggled to overcome past trauma. They could not break free from drug-seeking obsessions in the present, or make plans for the future. The difficulty of these struggles seemed to be related to their dwelling places: the worse the dwelling, the worse the distress of personal time. This captures the slippage from sanity to madness, the transition from good health to mental and physical suffering. To the temporally distressed person something may appear to be happening in the present that actually happened in the past, or that they fear will happen in the future. They are plagued with anxiety and may slip into hallucination and delusion. Psychiatrists call this “psychosis”. This may lead to a diagnosis of “schizophrenia” and a loss of freedom or worse.

Homemaking: Achieving the basic tasks such as cooking and eating meals, cleaning, decorating, hosting guests and/or pets, lying down, and sleeping soundly all appeared to moderate the day-to-day severity of mental disease. These tasks were more or less demanding depending on the dwelling type. Possessions with sentimental value help to keep one’s biography and identity intact; when these are stripped away so is the personal sense of time, and this may make psychotic depression more likely. The growth of self through homemaking seems to be crucial in overcoming the worst aspects of mental disease.

Management of mental health: In some cases there was severe tension between legal, social, psychiatric, and medical authorities’ demands and the participant’s own coping strategies. Psychiatrists and social-housing staff want to help, but they also want to control people living in the DTES. Veterans of the system get what they want and need either from their doctors or at the corner of Main and Hastings.

Contingencies of being poor in the DTES: Besides being one big “dope opera” the criminalization of “hard drugs” in the DTES means that psychiatrists/MDs, police, and violent syndicates combine to control people’s lives in the area. The drug market is tied to the sex trade, which is also criminalized. Therefore, survival sex-trade workers have multiple vulnerabilities; they’re caught between the police on the one side and drug and sex-trade syndicates on the other.

Fundamental human rights: The rights taken for granted by most people in our society such as access to nutritious food, adequate housing, or basic medical care are mostly out of the reach of poor people living in the DTES.

Some of my arguments include these:

Vancouver Coastal Health and UBC psychiatry have a deficient understanding of addiction and mental illness among the poor of the city. Use of hard drugs can be seen as adaptive behaviour that conditions the body in a way like an adequate home would. This helps people keep it together (or stay “well”) as long as they can keep consistent levels of dope in their system. This insight also helps explain how and why pharmaceuticals (like anti-psychotic and anti-depressants) sometimes work. This is also why the North American Opiate Medicalization Initiative (NAOMI) could work. In the absence of adequate dwelling spaces, drugs become the dwelling. Unfortunately, the researchers with the most political clout do not see understand it this way.

Psychiatrists tend to reify the American Psychiatric Association’s outdated Diagnostic and Statistical Manual (DSM) while pushing eugenics-style theories of inheritance and genetic counselling instead of recommending the eradication of poverty. In my opinion, the behavioral geneticist and city councillor Kerry Jang personifies a kind of bad science and hucksterism that complements billionaire developer-dominated civic politics. Taking the Woodward’s project as an example, I showed how architects, planners, psychiatrists, and nonprofits have re-institutionalized mentally ill people while reducing social housing and low-income rental stock. Patsy organizations like the Portland Hotel Society help fabricate an ethical narrative that is swallowed hook-line-and-sinker by the public. I call this “Vancouverism” and my research indicates that it is common in neoliberal cities around the world.

There are no comprehensive solutions to these problems from within our socio-political system. Despite political parties’ promises to “end homelessness”, it just isn’t going to happen in “Canada” or any other nation. Modern architecture, psychiatry, and psychology all suggest an abundance of solutions to these crises. However, they are appropriated by politically powerful coteries to further entrench their positions. It is possible that psychiatry can be salvaged in a stateless, classless society. It may then provide a sufficiently complex model to diminish, if not eliminate, severe mental illness. The Olympic Tent Village was an example of how resistance efforts can stem the crisis. That success compared with others from around the world, suggest a grassroots-led revolutionary transcendence of the nation-state model could lead to a “homes for all” situation. So the solution may lie in some combination of resistance and complexity.

Comments (12) Add New Comment
KC
Very interesting. Let them have it, Ed.
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Beatriz
Excellent article , enlightening. Unfortunately there is no grass root transcendent anything in the DTES.
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Durgan
Thanks you guys. I am very grateful to the Straight for publishing this and giving a chance for it to get to the community that made the research possible. I could not have done it without support from VANDU and DERA who hooked me up with research participants and helped me to establish a trusting rapport with them. Here is a link to the downloadable dissertation. It is about 480 pages total with about 200 pages of transcribed interviews with my participants in the index. http://circle.ubc.ca/handle/2429/45052
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Beatriz
Thank you Ed, I just downloaded , loooking forwards to start reading. Im taken by the dynamics of the DTES , and its alarming levels of dysfunction of both the community and those who are payed to provide "assistance ". For many years now the 2 forms of government that must take responsibility and address once and for all this man made human catastrophe had done nothing, instead money was and continues to be poor into unqualified individuals , what has come to my attention from these poverty employees is their total inability to foresee that their charity service play a retrograde roll and is useless when it comes assist the ever ongoing drama of mental health, addiction , dual diagnosis and trauma that defines the DTES, it takes more than a plate of watery soup or a creepy single room in some putrid hotel where even a pest exterminators refuses to enter , it takes much more and charity employees don't have the "know how" at the centre of it all charity is not justice and because it isn't it does not empower these wounded people but the opposite applies: it has hurt the people in the long term because it has perpetuated this human tragedy.
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Alan Layton
"There are no comprehensive solutions to these problems from within our socio-political system."

I don't think we are suddenly going to change the socio-political system in this country, especially for such a small fraction of the population, so time to come up with some truly unique and creative solutions, that will work within the system.
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Durgan
I agree with you Beatriz, this approach perpetuates the catastrophe. The Woodwards and PHS housing model should be seen for what it is: the new asylum model. We have people, the sickest of the sick, being treated by people with the least amount of training and expertise. The quasi-medicalized staff is supervised in the authoritarian styles of VCH psychiatrists and the society's directors. When I finished my clinical psych degree back in 98' I realized that 'social workers' can be seen as the complimentary half of an oppressed minority. Ironically it is usually people who themselves come from poverty. They are often survivors of foster care, formerly homeless youth or adults, or recovering hard drug addicts and/or sex workers. This can sometimes be an advantage. For instance, some rape trauma survivors make excellent rape trauma counsellors due to their experience. However, to be effective one would have to do a lot of advanced training on top of personal/therapeutic work and most social worker types have done neither. Without this they are out of touch with their motivations for pursuing this line of work and are likely to seek to satisfy their own unmet needs (resulting from past trauma and neglect) on the job. You see this most clearly where there are issues of "personal and professional boundaries." There is a great confusion in the field between sympathy, or pity, and empathy - a kind of interpersonal, embodied understanding also known as compassion. Empathy has been at the core of every effective psychotherapeutic technique since they were perfected in the 60's and 70's. It makes the therapeutic relationship possible and it is why you don't have to be a former addict to effectively counsel addicts for instance. In my opinion, if you read almost any interview with Liz Evans you can see that the core of PHS's approach since the beginning has been sympathetic, not empathetic. A recent study, called "the hotel study," completed by UBC psychiatry and Vancouver Coastal Health found that mortality at PHS sites is roughly equivalent to that of street homelessness, so we can see how effective this sympathetic approach is. This warehousing and pacification of impoverished dwellers begins to look a lot like palliative care, but it also serves the purpose of keeping the rabble down and hindering revolutionary change.
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Stephen Blumstein
Mr Durgan,

Your research on homelessness is hopelessly mainstream, and reflects a biased approach equating it with mental illness and drug addiction. Why is it skewed ?
Simple. It fails to take into account the hidden and relative homeless, and has a small sample size of ten (10), which is twenty (20) less than allowed by the Central Limits Theory. On the other hand, I have done research, with the aid of the Social Housing Alliance, on the scope of homelessness in British Columbia, and contrary to the 2,750 absolutely homeless counted in Mayor Robertson's (Vancouver, B.C.) study, I found that there were more than 116,000 homeless here in British Columbia at any one time.

May I direct your attention to another study on Vancouver hidden homelessness in 2009, done by Mustel and Associates, a research company I once worked for:

"Projecting to the total population of Metro Vancouver households,it is estimated that there were 9,196 hidden homeless persons at the time of the survey. Most of them would have been unrelated to the host household. The number of hidden homeless individuals in Metro Vancouver in the past year was estimated to be 23,543 persons. Most (18,000 or 75%) of these individuals were non-family members."
http://www.endhomelessnessnow.ca/homelessness-and-mental-health/ehn-news...


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Durgan
Thanks for your comment. This 'end homelessness now' campaign that sponsored the study you refer to is just what I have in mind when I refer to scientifically meaningless, political sloganeering and campaigning. There is more than one lower- mainland political hack associated with the 'end homelessness now' organization. The study you cite presents findings based upon dubious research design and aims, privately funded to boot. I have read dozens of similar papers from all over the U.S., Canada, Europe and elsewhere. This is not science, this is scientific method (technique) appropriated for political ends. These studies are designed to show effects for this or that program, which is proposed or carried out by this or that political party. You will find something comparable happening in most major cities in n. america and europe.

I'm not saying that it is not important to have some count of the homeless population, but the fact is that it is impossible to come up with precise numbers of any kind and, in my view, that casts insurmountable aspersions on your presumably statistically grounded claims.

The numbers of homeless and inadequately housed is very high and continuing to climb. I don't think there is necessarily an equivalence with this and mental illness, but I am convinced that there is a relationship. Nothing you state implies that my findings don't apply to the population you guys are looking at either btw.

Regarding my research design, well this is qualitative research so concepts of 'skew' and the 'central limit theorem' do not apply. However, as far as qualitative research goes I am drawing from a large data set.
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Wendy Pedersen
Ed, I appreciate this short form of your work because no time to read the full report. I am curious now and will read more. Your findings take into consideration socio-econ factors unlike Dr MacEwan's research, who's reports are continuously quoted by government. Can you explain this a little more online or off to me on FB?

"There is a great confusion in the field between sympathy, or pity, and empathy - a kind of interpersonal, embodied understanding also known as compassion. Empathy has been at the core of every effective psychotherapeutic technique since they were perfected in the 60's and 70's. It makes the therapeutic relationship possible and it is why you don't have to be a former addict to effectively counsel addicts for instance. In my opinion, if you read almost any interview with Liz Evans you can see that the core of PHS's approach since the beginning has been sympathetic, not empathetic."
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Beatriz


Indeed, Ed.
In a most unexpected place , according to some that seem to know the best place in the world to live, we find the rebirth of the asylum now as SRO's , oh boy Foucault was so right, and here in the DTES too the asylum attendants are as mad as the mad they they are pay to look after.
Naturally like any disease that goes untreated it has deteriorated , now I can not tell them apart if it wasn't for the clothes.
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Durgan
Hi, Wendy. I find Dr. MacEwan's research practically useless. What is its purpose? I think it is mainly to keep the grant-money wheels churning and burning at UBC psychiatry and VCH. The stuff that crew published on methamphetamine a few years ago was misleading at best imo and the hotel study adds almost nothing new to the conversation. Combined these two studies cost over half a million bucks and took about 7 years of labor.

I think there are many reasons for the failure of the PHS housing model, this one that I refer to is the most basic one. The stuff on empathy and its central roll in the therapeutic process is usually only emphasized in certain grad-level course work, in depth psychotherapy programs for instance. It was shown long ago to be the active element in psychotherapy long ago, most notably in the very first meta analysis on therapy techniques. PHS ignoring this fact is only part of the problem though, they also ignore the inevitable consequences of the sympathetic approach. One way to understand it is 'enmeshment' when social workers lose the sense of professional and personal boundaries with their clients, as is described in some interviews with PHS founders - this leads to all kinds of problems. Another consequence of loss of the empathetic rapport can be seen in all the staff members that go on power trips and end up bullying or otherwise taking authoritarian style approaches to shift work. This plus the asylum-style architecture and administration of space combine to produce PHS's high mortality rates. IMO nothing from this housing program should be replicated anywhere since it is flawed at its root and branch.
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Durgan
Also, to Alan Layton. Its been time to come up with some truly unique and creative solutions that work within the system for about 200 years now. My point is that the system itself, at its essence, has this problem built into it. Either we change the system through revolution, or we should finally admit, as you say, that we will not change the system for the sake of a minority - they will be doomed to die these wretched and torturous deaths as long as this age reigns. We must accept this. At least thats my position now, but I'm always open to being convinced otherwise.
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