Un-seeing

Homelessness has a broad meaning. Street homelessness refers to people who ‘routinely find themselves on the street during the day with nowhere to go at night’ (Diaz, Reference Diaz2006). It incorporates the term rough sleepers (people who sleep in the open air or places not designed for human habitation) as well as those who use temporary shelters, prisons and hospitals. Statistics on the number of rough sleepers are woefully inadequate, but best estimates suggest there were between 3000 and 4000 street homeless people in New York in 2016 (NYC Open Data, 2017). This is equivalent to the entire street homeless population of England for the same year (DCLG, 2016).

However, my epiphany came not in New York, but in Skid Row. This is one of the most impoverished areas of Los Angeles, with one of the greatest concentrations of street homeless people in America. I was visiting the (remarkable) Skid Row Housing Association, and my journey through the neighbourhood took me through street after street of simple tarpaulin tents with people in flagrant psychosis outside or intoxicated in the gutters. What was most astonishing was that this modern-day Gin Lane (Hogarth, Reference Hogarth1751), resting in the shadow of that great reminder of the American dream – the Hollywood Hills, was just two blocks away from the decision makers of Downtown Los Angeles.

I returned to New York with new eyes. I remember watching the well-heeled Manhattanites walk past countless homeless people on the street without seeing them. The look of shock followed by repulsion (and then sometimes compassion) when one was forced to encounter a street homeless person (for example by requests for money) emphasised the un-seeing: a process akin to denial, a step beyond ignorance. During my training, I had worked in an assertive outreach team for the street homeless in south London, so these reactions were not new to me, but it was the scale of the un-seeing in America that was staggering.

Seeing through a sociological lens

Homeless people occupy a third space between physical proximity and social distance. They are what the early German sociologist Georg Simmel called the ‘stranger’: ‘distance means that he, who is close by, is far, and strangeness means that he, who also is far, is actually near’ (Simmel, Reference Simmel and Wolff1950). Strangers may come into contact with society but they are excluded from it. Who could be more alienated than the homeless? They are the daily reminders of society's failures.

There is a strong dissonance in that statement: these are the people that have been failed by society, but they are also the people that society chooses to typecast as ‘failures’. The tragedy is that homeless people have the additional perverse burden of bearing the blame for their own exclusion. Research in people with mental illness routinely shows that prior experience of discrimination leads individuals to expect discrimination and anticipate stigmatisation, which in turn can lead to a belief that stereotypes are warranted (Quinn et al, Reference Quinn, Williams and Weisz2015). Similar pathways to internalised stigma have been described in homeless people (Belcher & DeForge, Reference Belcher and DeForge2012).

Stigma literally means a ‘mark’, and the more visible the mark, the stronger the stigmatisation. The homeless people that were most visible to me were those who were clearly psychotic or intoxicated. Within the population of homeless people, 20–35% have a diagnosable mental illness and the prevalence of psychotic illness and substance dependence is several magnitudes higher than in the general population (Rees, Reference Rees2009). But social researchers make an interesting point: they believe in the correlation between mental illness and homelessness, but not in a direct link. When the prevalence of mental disorders among all classes of homeless people (for example, including homeless families) is compared with the domiciled poor people from the same geographical area in America, the rates are almost equivalent (Draine et al, Reference Draine, Salzer and Culhane2002). Could the marginalisation of homeless people in society, and to a degree also those with mental illness, actually be evidence of a wider contempt for the poor?

Seeing through a societal lens

American society is infused with the idea that any person can achieve success given the right amount of ambition and dedication, i.e. that people get what they deserve. This is the American dream. It is a noble ideology, if only it were true: America has the least socially mobile economy in the high-income countries of the world (followed by the UK) (Corak, Reference Corak2006). The story told by one homeless woman, Mary, reinforced the damaging gulf between the American dream and the true reason for her circumstances: sustaining permanent nerve damage in an industrial accident, she lost her job, her house and started living in her van. For Mary and many people who passed her by, she was to blame for what she did not have.

How we respond to homeless people can be seen as a reflection of how we respond to injustice generally. The need to believe in fairness is deeply ingrained in us; yet the world is a self-evidently unjust place. Decades of research has shown that, when faced with injustice, we will try to lessen it; but if we cannot do so, we will reassure ourselves that people deserve what they get. This is the flip side to the American dream. The classic experiment that postulated this ‘just-world hypothesis’ was conducted by Lerner and Simmons in the 1960s (Lerner & Simmons, Reference Lerner and Simmons1966). In it, people were shown a video of a woman receiving ever-increasing electric shocks. When given the option to stop her punishment, almost everyone did; but if not given this choice, the witnesses rationalised that she must have done something to deserve her torture. Her pain was the proof of her guilt, and so the fairness of the world was restored. Lerner and Simmons wrote ‘the sight of an innocent person suffering without possibility of reward or compensation motivated people to devalue the attractiveness of the victim in order to bring about a more appropriate fit between her fate and her character’.

Several studies have related similar reactions to homelessness. Ten years ago, Toro et al (Reference Toro, Tompsett and Lombardo2007) found that America and the UK had the greatest lifetime prevalence of homelessness but spent the least on social welfare and had the least compassionate public attitudes to homeless people. Respondents from America in particular were most likely to endorse personal failings as an important cause of homelessness and the least likely to support increased federal spending to help homeless people. Contrary to expectations, exposure to socioeconomic inequality in unequal societies has been shown to reduce support for redistributive economic policies (Sands, Reference Sands2017). Although both the UK and America share a ‘special relationship’ in terms of values, culture and socioeconomic factors; I think the ubiquity of street homeless people in America overwhelms the public's capacity to intervene and so just-world rationalisations are employed much more.

The American dream is a contract between society and the individual: where society will provide a level playing field on which, by working productively, the individual can achieve success. Homeless people are evidence that this contract is broken and the world is unjust, which is terrifying to a society that prizes individualism above other attributes. Projecting those fears onto another individual, who will then internalise them, is an effective collective defence. Homeless people bear the cost for the rest of America to believe in the dream.

Perspective

The moral challenge that homelessness represents applies equally to politicians, religious leaders, voluntary sector workers and healthcare professionals on both sides of the Atlantic. After all, the conservative notion of self-sufficiency and self-improvement in the UK uses similar just-world arguments as the American dream to explain social exclusion. Psychiatrists have a unique role to play in reframing the discourse around these powerful societal processes. There is a clear clinical need to better manage mental illness in the homeless population, irrespective of whether its prevalence is comparable to an equivalent domiciled poor population or not. Mental illness in homeless people acts synergistically with other medical and social illnesses. Psychiatrists, who are conversant in these complex interactions, are well placed to coordinate care for homeless people across multiple agencies and within multiple disciplines. Beyond the clinical and organisational considerations, as a profession we have a powerful voice and platform with which to achieve a different settlement for homeless people: one in which not just the quality of life of individuals but also decisions of equity and the cohesion of society as a whole need to be renegotiated. Ultimately, all people are not born equal, but equity is conferred upon us throughout our lives by the actions of others.