This post is part of a collaborative narrative series composed of my writing and Chris Arnade's photos exploring issues of addiction, poverty, prostitution and urban anthropology in Hunts Point, Bronx. For more on the series, look here.


OBJECTIVE: The authors examined the prevalence of and risk factors for homelessness among all patients treated for serious mental illnesses in a large public mental health system in a 1-year period. The use of public mental health services among homeless persons was also examined.

METHOD: The study included 10,340 persons treated for schizophrenia, bipolar disorder, or major depression in the San Diego County Adult Mental Health Services over a 1-year period (1999–2000). Analytic methods that adjusted for potentially confounding variables were used. Multivariate logistic regression analyses were used to calculate odds ratios for the factors associated with homelessness, including age, gender, ethnicity, substance use disorder, Medicaid insurance, psychiatric diagnosis, and level of functioning. Similarly, odds ratios were computed for utilization of mental health services by homeless versus not-homeless patients. RESULTS: The prevalence of homelessness was 15%. Homelessness was associated with male gender, African American ethnicity, presence of a substance use disorder, lack of Medicaid, a diagnosis of schizophrenia or bipolar disorder, and poorer functioning. Latinos and Asian Americans were less likely to be homeless. Homeless patients used more inpatient and emergency-type services and fewer outpatient-type services.

CONCLUSIONS: Homelessness is a serious problem among patients with severe mental illness. Interventions focusing on potentially modifiable factors such as substance use disorders and a lack of Medicaid need to be studied in this population.¹

Sonya, Philadelphia. Courtesy of Chris Arnade.

Inside Sonya's place, a pair of shoes sits toe-to-heel on a ledge, buckles dull and rusted. It would be unlike Sonya to wear them, as unimaginable as her wearing silver hoop earrings, or wearing anything fanciful at all. She, a beacon of street practicality, has no fancy.

Further inside her place, the abandoned backside of a gas station, pairs of pants hang off a wooden hutch, a structure akin to an old shed, in the recesses of the brick. A space for living and for hiding. To access to it means climbing a wall, over and under collapsed ceiling planks that form sharp angles. Against the wall, her panhandling sign is missing.

Outside, posts with stickers read, "Hi My Name is Barn!" and people drive the wrong way down an abbreviated one-way street.

In Philadelphia, Sonya has a daily march that takes her under the elevated train, a walk alongside a neighborhood touting Earth Day signs in bars before turning into a land of plastic-cup shots in bodegas. The public school on her route bears "no hoodies allowed" signs.

After her husband Eric was arrested and sent back to New York on a felony warrant, things got worse. She did things she didn't want to do for money. For a time, she worked as a madam in a crack house and did okay.

On a day where she made enough money after buying drugs, she caught a bus back to the city to be near Eric and slipped into her Hunts Point routine--

Sonya, Hunts Point. Courtesy of Chris Arnade.

Her con is a hunched shuffle with a cardboard sign, here under an expressway. She floats back and forth alongside a left turn lane, one consistently backed up with semis. It could be raining, snowing.

She holds the rectangular cardboard that folds into three, like every panhandling sign she's had, with edges that bend in the wind's movement. “Homeless. Need job. Please help.”

The con wasn't as profitable in Philadelphia, didn't work as well against the frame of open dealing and glassy-eyed addiction in doorways. A problem or five at every corner, skinny men and women who wore their skin as if their soul wasn't inhabiting. She did less drugs then. There was less money to go around.

At first, she makes plans to visit Eric. She learns she cannot do this without state ID, cannot communicate without a phone from which to pay money to receive his calls, cannot receive letters without an address.

She starts yelling hateful things in public places, cutting her wrists in police cruisers. She goes into and of out psychiatric treatment for days at a time, only to return to the company of her eight traffic lanes.

Inside hospitals, she makes loud requests for visitors to buy and bring her heroin. When they don't come through, she makes threats, screams racial slurs at attendants. Her body hurts everywhere without heroin. Doesn't anyone understand the pain?

In withdrawal, she defies orders, insists on leaving. Back outside to Hunts Point, she becomes reclusive. Her appearance wears. People, her friends, stay away in accordance with her wishes. They worry, unable to do more.


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