ALEX COHEN

THE SEARCH FOR MEANING: EVENTFULNESS IN THE LIVES OFHOMELESS MENTALLY ILL PERSONS IN THE SKID ROW

DISTRICT OF LOS ANGELES

ABSTRACT. In the past two decades, the field of psychiatry has seen the once dominantpsychoanalytic theories overtaken by biological explanations and approaches to severemental illness. With this change in perspective, the significance of fantasies and delusionshave been reduced to being merely symptoms of psychopathology rather than reflectionsof human needs and motivations. Using ethnographic evidence from a long-term researchproject, this paper explores one method by which mentally ill homeless individuals in theSkid Row district of Los Angeles attempted to wrest meaningful lives for themselves outof an environment that featured disaffiliation, violence, boredom, and extreme poverty.

None of us is perfectly adequate in terms of our culturally established expectations, and allof us manage our affairs so as to hide from others those imperfections we know to exist. . . .We all, it may be said, in varying degrees manage fictional lives through a fictional world.(Goldschmidt 1967: vii)

INTRODUCTION

Meeting Carl

One afternoon, while walking west on 6th Street in Skid Row, I happenedupon Carl,1 who was walking in the opposite direction. We greeted eachother and I took the opportunity to ask if he wanted to get togetherthe following week. He said that would be fine but needed to check hisschedule to see when he was available. With some pride, he added that henow had an appointment book – just as I did. His need for an appointmentbook struck me because it seemed so out of place for a homeless mentallyill man in Skid Row, a place where life was dominated by boredom andinactivity, only interrupted by brief periods of violence and terror, muchlike the experience of war. At the same time, Carl’s comment that heneeded to check his schedule was perfectly in keeping with what mostof us do. Who among us would think of making an appointment withoutconsulting some prosthetic memory device to be certain that the time inquestion was available, often doing so with a display of the extent towhich one’s calendar is filled with activities and obligations? How many

Culture, Medicine and Psychiatry 25: 277–296, 2001.© 2001 Kluwer Academic Publishers. Printed in the Netherlands.

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of us find ourselves regularly discussing with friends and colleagues theextent of our busyness? How we are working on three different projects orhave made commitments to write articles for half a dozen journals or haverecently gone to distant places to consult on important programs and givelectures? Carl was simply doing the same. It was one method by whichhe could impress upon me that his life was driven by forces and concernsthat were much the same as mine. In fact, to a greater extent than most ofthe homeless mentally ill persons I knew, Carl did have a busy schedule– working at different times in the kitchens of two shelters and regularlytaking part in events and programs sponsored by these organizations. Evenso, his comment was notable and stayed with me.

Sometime after this incident, I noticed that a principal character in thepopular television program, L.A. Law, was virtually never seen withouthis appointment book in hand. Was it a talisman? A holy text? A scepter?With that image pointing the way, I began to think that what Carl had saidsignified something more than an isolated or odd comment. Indeed, I havecome to believe that his appointment book was emblematic of a central andpowerful feature of life for the homeless mentally ill persons I knew, andthat it offered a valuable perspective from which to consider the meaningof some of the delusions associated with the severe mental illnesses fromwhich they were suffering.

Delusions and fantasies have long been noted as central featuresof psychosis. From Esquirol (1845) to the DSM-IV (American Psychi-atric Association 1994) delusions or fixed, false beliefs have remaineddiagnostic criteria for schizophrenia and other psychoses. Attempts to clas-sify (Butler and Braff 1991), and define (Spitzer 1990) delusions, have notquestioned that the false nature of these beliefs, despite evidence fromexternal realities, is central to the concept. The same consensus is notfound in explanations for the development of delusions which can bedivided generally into two categories. One set of theories postulates thatdelusions arise out of fundamental deficits in cognitive processes, whilethe second category considers delusions as the products of psychologicalprocesses. While both explanations consider delusions as false beliefs,their meaning is quite different. The implication of deficit theories isthat delusions are symptoms of impairments in biological or cognitiveprocesses, not dissimilar to fevers produced by bacterial infections, butnot of primary interest. On the other hand, psychological explanations ofdelusions, psychoanalytic theories in particular, presume that delusionsdevelop from experiences in childhood and the interaction of uncon-scious defense mechanisms. In this view, delusions are the outwardexpression of inner emotional needs and conflicts (Arthur 1964), and

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do not differ qualitatively from the modes of expression found amongindividuals who are not suffering from severe mental illness. Indeed,psychoanalytic theorists believe that all human expression is meaningful(Fromm-Reichmann 1959).

In the past two decades, the field of psychiatry has seen the oncedominant psychoanalytic theories overtaken by biological explanationsand approaches to severe mental illness (Eisenberg 1986). With this changein perspective, a number of authors have noted the neglect of meaning bybiomedical psychiatry. The anthropologist Ellen Corin (1990: 156) writes,“the disease is seen as a reality outside individual experience, a realitythat has its own dynamics.” Anne Lovell (1997: 356), another anthropolo-gist, maintains that biomedical psychiatry places persons diagnosed withschizophrenia “outside the realm of shared symbols and notions of self.”Both Corin and Lovell argue for a meaning-centered, human perspectiveon severe mental illness that makes psychotic behavior and delusionssubjects of importance and worthy of investigation.2 Psychiatrists, too,have questioned the current lack of attention to meaning in their field.Glenn Roberts (1991) in keeping with the theories of Harry Stack Sullivan(1953) considers delusions to be adaptive efforts to attribute meaning toexperience while in the search for order and security. Finally, John Strauss– one of the leading schizophrenia researchers in the past 30 years – hascome to question the narrow concern of biomedical psychiatry with theassessment and treatment of measurable symptoms (1989). Treatment, hemaintains, must be aimed at something more than symptom alleviation,e.g., the removal of delusions. In a paper titled “The Person with Schizo-phrenia as a Person,” Strauss (1994: 105) writes, “There is [a] deeper,richer, perhaps more human aspect of experience which in our field is sooften neglected.”

In this paper, I offer a further elaboration on the importance of meaningin the lives of severely mentally ill individuals. I will begin with a briefdescription of the research, and the subsistence adaptations utilized byinformants. Following a discussion of the concept of eventfulness, I willexplore one method by which certain mentally ill homeless individualsattempted to wrest meaningful lives for themselves out of an environmentthat featured disaffiliation, violence, boredom, and extreme poverty. Inconclusion, I will suggest that an exclusive focus on psychopathology anddisability does an injustice to individuals with severe mental illness andneglects a basic aspect of their humanness.

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ADAPTATION OF THE HOMELESS MENTALLY ILL PROJECT

The Adaptation of the Homeless Mentally Ill (AHMI) was an ethnographicresearch project in which five anthropologists followed fifty homelessmentally ill individuals in the Skid Row district of Los Angeles fromNovember 1987 through May 1991.3 The primary goal of the researchwas to document, as completely and accurately as possible, the day-to-day lives of the informants by examining the nature of their subsistencepatterns, social networks and support systems, attitudes toward and utiliza-tion of services, and course of homelessness (Koegel 1992). Although anopportunistic sampling method was used to select informants, an effort wasmade to include individuals who represented a full range of heterogeneityin regard to the use of subsistence services, relationship to the mentalhealth care system, the types and stability of their living arrangements,age, functional status, and their overall coherence and ability to commu-nicate. The last criterion was particularly important because ethnographicmethods made it possible for us to work with individuals who wouldhave never been able to tolerate a lengthy interview and, thus, would havebeen excluded from survey research. Although some informants were notparticularly communicative, we were able, through participant observa-tion, to document the behavior of individuals over time and in a variety ofsettings, producing rich, detailed understandings of their lives even whenthey refused or were not able to speak with us.

Skid Row

The Skid Row district is approximately one square mile in size and lies,roughly, to the south and east of the steel and glass skyscrapers of down-town Los Angeles. Its boundaries are Broadway to the west, First Street tothe north, Central Avenue to the east, and Eighth Street to the south. Anestimated 5,000 homeless persons inhabit the area (Koegel et al. 1993). Ifone accepts a prevalence rate of 25 percent for severe and chronic mentalillness among the homeless in Skid Row (Farr et al. 1986; Burnam andKoegel 1991; Koegel et al. 1988), there are about 1,250 mentally ill home-less persons in the area on any given night. In addition to mental illnessand homelessness, this group is also burdened with high rates of alcoholand drug use (Koegel et al. 1988; Cohen and Koegel 1996).

For me, Main Street demarcated the real western boundary of SkidRow. To the west, the streets and sidewalks were crowded and inexpensiveshops and restaurants occupied the ground-levels of the pre-war officebuildings that lined Broadway and dominated the sky. As one walkedeast, it was at Main Street that the large buildings gave way to one and

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two storied structures and the bright, smoggy Southern California skyreasserted itself. Here the sunlight was brilliant in sharp contrast to thedingy, rundown environs, and the weary, wired, or troubled people wholived in the district. It was east of Main that one found sidewalk encamp-ments of homeless people in “cardboard condos,” flimsy shelters that werefashioned from corrugated boxes. On San Julian Street, just north of 7th,intravenous drug use went on openly, and hypodermic needles were sold ata bar on the corner. I will never forget walking down the street and takinga wide berth around two men as one held his breath and puffed up hischeeks while the other stuck a hypodermic needle into a distended vein inthe neck of the first. It was east of Main that 5th Street became what wecalled “Ground Zero” – a place so filled with violence, substance use, anddisaffiliation that one had the sense of being at the center of a devastatedworld. East of Main the streets were filthy and often stank from garbageand human waste. Here were the worst single-room occupancy hotels,infested with vermin of all kinds and human predators. Theft, robbery,and assault were constant threats. One informant was stabbed in a hallwayof the hotel in which she was living, and then evicted as a troublemaker.Another would cower in fear as people pounded on his door throughoutthe night. Some hotel managers demanded bribes to guarantee that renterscould retain their rooms from month to month. Hotel managers also servedas loan sharks, at an interest rate of 100 percent, and thereby gained controlof the finances of many individuals. From this perspective, the “choice”to live on the streets seemed reasonable, even though life there, too, wasfraught with danger.

Skid Row was a small world that stood apart from the rest of LosAngeles – unknown to the majority of those who lived in other areas ofthe county; mostly ignored, neglected, or hated by those who did know ofits existence.

To a great extent, conducting ethnography in Skid Row was an exercisein documenting sadness, despair, and disability. On walking into the UnionRescue Mission one was struck by the hundreds of men sitting on plasticchairs doing nothing – simply staring into space or dozing. About halfof the AHMI informants struggled with alcohol and drug problems. Foursample members were HIV+ and another seven were, because of drug useand sexual behavior, at high risk of becoming infected, if they were notalready. During the period of fieldwork one man developed cataracts andwent blind; another began to suffer from the effects of neurosyphilis; onewoman slipped into alcoholism and severe depression; another succumbedto crack and became ensnared by a world in which she was regularly beatenand raped.

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Of the first day that she and Jackson Underwood began fieldwork, DanaBaldwin wrote:

Sitting on a brick planter next to us in front of the Fire Station was a filthy blond, blue-eyedmentally ill homeless man who looked to be in his 20s. He was crying and babbling awayabout different things, among them something about being a Vietnam Veteran. He clearlywas in extreme distress and was trying to communicate this, but he wasn’t able to do it inany coherent way. While I (unsuccessfully) tried to understand him, I, like everyone else,left him to endure his psychic, psychotic pain alone. . . .

The most important aspect of our fieldwork, however, was beingallowed into the lives of the informants. Perhaps the best description ofour role was offered by one man who, in explaining to an acquaintancewhy Paul Koegel had accompanied him to a court appearance, said, “He’smy anthropologist.” As such, we served as companions, confidants, andbiographers. My colleagues and I shared meals, drank coffee, and hung outwith informants; played cards and chess with them; listened with interestand made notes about or recorded our conversations both lengthy and brief.We visited informants in their apartments or hotel rooms during periodswhen they were off the streets. We took them out to eat at local restaurants.In short, we took an active part in their lives.4 Jackson drove one man tothe hospital when he was suffering from seizures. Dana took a womanon excursions to Magic Mountain, Disneyland, and Universal Studios.Tom Ward spent hours listening to one informant explain his “chemicalformulas.” He helped a Spanish-speaking informant fill out an applicationfor Supplemental Security Income (SSI) and accompanied him to a varietyof medical appointments at Los Angeles County Hospital.5 I took inform-ants to the Zoo, Santa Monica Beach, and the L.A. County Museum of Art.I visited informants in the L.A. County Jail and, when one was transferredby the court to Metropolitan State Hospital, I visited him there.

These activities helped to establish rapport, provided relaxed atmo-spheres in which to talk, and provided many individuals with meals thatthey might not have had otherwise. While these excursions and endeavorswere certainly a means to compensate informants for their participation inthe research, they also broadened our understanding of the lives of inform-ants. By observing behavior in many different settings, over a substantialperiod of time, and in a wide range of psychological states, the fieldworkprovided us with a “native’s point of view” about Skid Row, homelessness,and mental illness.

Subsistence Adaptation

The term subsistence adaptation is used here to denote the strategies thatindividuals employed in their efforts to meet their basic needs for food,

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clothing, shelter, money, companionship, positive affect, health care, etc.,and the role that they took in responding to external forces. In brief,the ways in which individuals attempted to meet their basic needs wasshaped by the lack of viable options in the Skid Row environment, externalfactors such as racism, poverty, and violence, and internal pressures suchas psychosis, substance use, and personal inclinations. While it is true thatcertain individuals fit various stereotypes of homeless mentally ill persons,the categorization of informants into subsistence adaptation typologiesrisks the danger of masking information rather than encapsulating it insimplified form (Cohen and Koegel 1996). For example, at the begin-ning of the research, about one half of the informants were living on thestreets, about one third were in shelters, and the remainder were livingin hotels. We learned quickly that these initial impressions were, in manycases, misleading. Situations often changed, and in ways that were diffi-cult to predict. Depending on finances, psychopathology, substance use,and personal inclinations, individuals would sleep on the streets, utilizeshelters, missions, and hotels, or even rent apartments. Much the samewas true for other subsistence domains, e.g., food and clothing. Strategiesfor meeting basic needs changed continually in response to a variety offactors, and made discrete subsistence typologies difficult to establish. Inaddition, evidence from our research supports the notion that outcomes insevere mental illness are distinguished by “open-linked systems” (Straussand Carpenter 1977). That is, abilities in one subsistence domain were notnecessarily present in another domain. For example, because an informantwas actively psychotic did not mean that she was incapable of maintainingherself in an apartment independently; nor did living on the street indicatean inability to maintain one’s personal hygiene.

Most importantly, one should not assume that informants were passiveobjects in the face of a hostile environment, or that they were sobuffeted about by mental disorders and substance use that it was virtuallyimpossible for them to act on their own behalf. Very much the oppositewas true. The informants were motivated actors who struggled to meet awide range of subsistence needs (Goldschmidt 1990) within an environ-ment that would have taxed the abilities of anyone (Koegel 1992). Theydevised strategies to satisfy their basic needs and then modified them asdecision algorithms were revised according to external forces and shifts inthe priority and status of competing needs (Cohen and Koegel 1996).

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THE SEARCH FOR MEANING

Eventfulness

While conducting ethnography in a sheltered workshop, Graffam andTurner (1984) came to recognize that boredom was an important aspectof the lives of the mildly mentally retarded adults who worked there.Given the constraints on their lives – lack of social contacts outside theworkshop, cognitive deficits, poverty, little or no education, dependenceon family members – they had few opportunities to disrupt the monotony.More problematic, they were surrounded by a world that equated full socialand work lives with being normal, and busyness with importance. If “themaintenance of self-esteem and the presentation of a positive social iden-tity are related to the relative degrees of boredom and eventfulness that oneexperiences,” (Ibid.: 121) how could the workshop members think of them-selves as leading worthwhile lives when television and films presentedstarkly different images of what life should be like? When the profes-sionals with whom they had contact seemed so accomplished and smart?When the people in their own families had boyfriends or girlfriends, gotmarried, had jobs, went on vacations, and traveled?

Therefore, many engaged in an ongoing search for eventfulness. Thatis, they made attempts to infuse their lives with meaning through the useof “grandiose claims of personal achievements or exploits, highly drama-tized or emotional responses to apparently mundane events, and . . . intenseinvolvements in a fantasy life” (Ibid.: 122). The telling of stories, theintense involvement with the fantasies, and the belief that one’s life wasbound up with important people and events, provided participants in theworkshop a literal “escape from boredom.” While such behaviors could beviewed as delusional or pathological, Graffam and Turner believed theycould also be interpreted as setting-specific, adaptive behaviors by whichthese individuals sought to appear “normal” and to give the impression thatthey led “normal” lives.6

Elsewhere, a more literal concept of eventfulness was suggested tounderstand substance use among the AHMI informants (Cohen and Koegel1996). The pursuit of drugs and alcohol, their use, and the associated sociallife on the streets provided action and purpose that were absent in theprevailing boredom of Skid Row. The individuals that we knew had fewother avenues by which they could satisfy their need for meaningful socialinteraction and excitement. Moreover, the use of drugs and alcohol offeredan obtainable goal and a central theme around which to organize activities.One must understand, too, that substance use was a normative behaviorin Skid Row during the time of our fieldwork. The streets were littered

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with spent butane lighters, essential items in the tool kits of drug users.Given such an environment, and the virtual absence of positive, readilyavailable life pursuits, it is difficult to imagine that a majority of homelessmentally ill persons would have been able to avoid being taken in by thelure of drugs and alcohol even when the disastrous effects were evident.Substance use was a self-destructive strategy to fend off anomie.

The use of drugs and alcohol was not the only method by which indi-viduals dealt with the lack of eventfulness in their lives. Much like thementally retarded adults whose behavior was described by Graffam andTurner, AHMI informants told fabulous stories about themselves and theirlives. While it was true that many of these accounts can be interpretedas products of severe mental illness – manic expressions of grandiosity,for example – I will make the argument that these confabulations can beunderstood from another perspective – that they represented attempts toconstruct positive self-images and meaningful lives ou of the only solidbuilding materials available in Skid Row: fantasy and delusion.

One informant, more than any other, exemplified the need for event-fulness. From the first time Paul met William in December 1987 to thelast time that I saw him in May 1991, William regaled us constantly withaccounts of his remarkable life – the famous people he had known, hisongoing struggle to create a better world, and the outrageous persecutionsthat had been inflicted upon him and against which he was waging manylegal battles.7 The following examples represent only a small fraction ofhis presentations.

In the course of his many travels, William had met Robert F. Kennedy,as well as John F. Kennedy’s son. During one fantastic month in SanFrancisco he met the mayor, the chief of police, and Mother Theresa.During a sojourn in Phoenix he encountered the mayor of that city as well.Indeed, mayors were a recurring theme. William disliked the mayor of LosAngeles who, he believed, had allowed the city government and policeforce to become riddled with corruption. To make things right, Williambecame an “undeclared candidate for mayor,” so that he, an honest man,could clean up the city’s political scene.

During a walk along Broadway with Paul, William recounted how hehad once visited Sally Rand, the famous exotic dancer, in a nearby hotel.On getting to her room, his expectations for a sensuous evening weredashed. Ms. Rand told him that she was sorry – she was a married womanand a correct woman who was only trying to make a living. William,gentleman that he was, left immediately.

He spoke often of being a Franciscan priest and that his foster fatherwas a multimillionaire. He claimed to possess remarkable powers of “para-

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psychology” that allowed him to undergo surgery without anesthesia.Once, William informed me that he had hitched a ride from Phoenix toLos Angeles with the man who owned the Greyhound Corporation. Thenext time that I saw him, William declared that he was now the presidentand owner of Greyhound. It came as no surprise when William announcedthat a Hollywood producer was planning to make a film about his life. Mylast encounter with William was both typical and unusual. He went on inhis usual fashion. In particular, he mentioned that he was planning to geta divorce from his wife in Chicago, because he was worried that when hewon all of his law suits and became a multimillionaire his wife would gethalf of the money. So, he was planning to divorce her before the suits weresettled – that way he would be able to keep all of his riches. At the sametime, he did not seem to be himself:

First, he kept getting my name wrong. Referring to me as Alan, which he does much of thetime, hardly counts. But calling me Paul is something else again. . . . Second, he seemeddepressed. He talked about not running for mayor and regretting it. The reason for givingup on this ambition was a result of William’s physical condition. He talked about dying.Last week, he was sick for a few days. Previously, when he has talked about having AIDSand dying, William has been angry; today he seemed resigned. . . . From nowhere, [he]asked if I wanted to go with him to the bottom of the ocean or outer space.

After having a cup of coffee at a local restaurant, we walked back tothe shelter. Along the way, William bent down and picked up an emptysoda can since recycling was one way he supplemented his governmententitlements. He told me that he had to be careful, however. The managerof his hotel had warned that if he saw any cans in William’s room, he wouldbe evicted.

Although William was unusual in the extent to which he engaged inthe construction of an eventful life, he was certainly not alone in doingso. One informant spoke of having an IQ of 280; another professed tohave extraordinary musical abilities. Wealthy relatives were not unusual.One man claimed a famous book, “Hermaphrodite Man,” had been writtenabout him. Another said he was the King of Africa. Given the realitiesof their lives in Skid Row, it was not surprising that fantasy and delusionwere the main ingredients of their presentations of eventfulness. Giventhe values of wider society, it was even less surprising that many inform-ants constructed eventfulness around a number of common themes, amongthem assertions of normality, higher education, and work.

Assertions of Normality

The AHMI informants often made assertions of their normality in whatI would say were efforts to place their lives and self-images in line with

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sociocultural expectations about experience and accomplishment. On twooccasions, Roosevelt administered orientation tests to himself to prove, atleast to me, that he was mentally competent. Once, while we were walkingalong San Julian Street, he insisted that I take out my tape recorder andturn it on. I did so and he began, “Today is . . . the beginning of Novemberand . . . I’d like to be the first to wish you a happy Thanksgiving and thatthe President of the United States is George Bush. And that . . . I’m a verygood looking man.” I asked him if that was all he wanted to say. “Keepit on,” he replied emphatically. I assured him that I was keeping it on. Herepeated that the president was George Bush and that he was “a very goodlooking man. A very handsome man. I’ve been thinking about that.” I askedRoosevelt what he’d been thinking about:

That I’m really a very handsome man. That, in lieu of my . . . the reasons for coming outhere which would be, to be in the movie industry in some kind of fashion. What with myformal matriculation moving to the fourth I had . . . well . . . I’d better be careful when myover exuberance over takes me, ’cause my good looks and my RTD8 bus pass will get meon the RTD if I don’t get ripped off for it. . . . Reiterively [sic] speaking. . . . Perhaps betternot waste too much tape. Turn it off now.

I did. This incident was remarkable in several ways. First, Roosevelt wasclearly troubled by being perceived as mentally incompetent and wantedto demonstrate and document that this was not true. Second, his commentabout over exuberance was a euphemistic, yet perceptive, way of referringto the manic phases of his bipolar condition. Finally, realizing that he wasbeginning to stumble in his own test, he asked me to turn off the taperecorder. Even then, he attempted to protect his self-esteem with the excusethat he did not want me to “waste too much tape.”

Another informant, Don, was passionate in refuting the label of beinginsane. Early in our acquaintance, he stressed this point and made it clearthat he had no desire to spend time with me if I was going to support thevalidity of that label.

All I’m saying is, my question to you is, are you ready for the truth or do you want totalk shit and call me insane? ’Cause that’s why, y’know, I see them coming at me thesepsychiatrists. I see them come and they go. If they never heard of it, it is not going on.And that’s all they do. “Shit, you’re crazy, nigger.” And then they laugh. Y’know why?Because they run the world. Because they prove it to me that you’re nobody. “Hell, he’llnever believe you so what you doing telling?” I don’t need people who, y’know, who don’tbelieve things. You see what I’m saying? I’m not crazy, man. I have a lot of brains. Idrink coffee like everybody else drink coffee . . . people who drink coffee are good people,y’know? I am not crazy. . . . I have a lot of brains. Y’see what I’m saying? I’m looking outfor myself.

One should not assume from this statement that he denied his mentalillness, however. He simply did not want his worth as a person to be

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dismissed because of it. He would acknowledge his mental illness at times,but maintained that it was not permanent. Upon reaching his 35th birthday,he was certain it would disappear, he would move away from Skid Row,and his father would make amends for his neglect.9

Higher Education

Informants often spoke of their credentials from institutions of highereducation.10 One claimed to have not one baccalaureate degree, but four– from four different colleges and in four different disciplines. Anotherclaimed a Ph.D. in English Literature from the University of Iowa. Twoother informants spoke of having studied psychiatry at UCLA or havinggone to Princeton. William impressed on us, many times, that he hadseven and a half years of college credits and a Ph.D. in business admin-istration and management. For Roosevelt, college was fundamental to hiscreated identity. He spoke often of his full scholarship to Yale and how,although he had dropped out, he could go back at any time and takeup his study of French. Once, following several months in New Haven,Roosevelt explained that his scholarship required him to check in with hiscounselor at Yale every so often. After extensive discussions, Rooseveltand his counselor came to the decision that it would be best for him toreturn to Los Angeles and gain more “experience.” Through this “exercisein socialization,” Roosevelt would expand his knowledge of the world, andupon his eventual return to Yale, be able to impart invaluable knowledgeto his classmates. The “rich kids,” as he called them. While explaining allof this, and claiming that living on the streets was a requirement of thescholarship, Roosevelt revealed that he had gone to New Haven becausehis father had died; he then quickly returned to the topic of his associationwith Yale.

Work

Many informants held onto the concept of working as important to theiridentities. Roosevelt, for example, declared that with his fluency in Frenchhe would have no trouble getting a job as a language instructor. Don kept ajournal everyday, and meticulously headed each day’s entry with his name,the address of the shelter at which he stayed, the date, and the words,“Communication Job,” a reference to a job he had once held while in themilitary. Keeping the journal was more than an exercise in self-expression,documentation,11 and philosophical musings. It was his job and he took itseriously.

Still another informant, Dean, claimed he was a skilled auto mechanicand had worked for drag-racers. At one time, he was a master mechanic

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and a manager of an auto shop, but since going on his “pilgrimage” inquest of “self-evolution,” he confessed to having “gone down the ladder”and was now just an ordinary mechanic. Dean spent a great amount of timeworking on his lengthy résumé and looking for work. His search for a jobstarted in Skid Row and then expanded in an ever-widening circle in aneffort to find the right garage. Dean devoted an equal amount of time inthe Santa Monica Public Library conducting research to develop various“designs,” one of which would give “super power” to a gasoline engine.

Two informants, in particular, constructed their identities around jobs.The first was Bill, an older man who was described by Dana as lookingvery much like Popeye. The central focus of Bill’s life was collecting allmanner of found objects and organizing them in a shopping cart. On oneoccasion, Dana noted the following in his cart:

a full page color photo of a vamp in a sexy dress, a cat calendar, a small inexpensive blackplastic gun, two plastic watches (that didn’t work), two whistles, a corn cob pipe, a lightbulb, a man’s diamond ring (which he later said he’s trying to sell for $10), a Clinique soapcontainer with change inside, a small brown date book, inside of which he had a dollar,and a mysterious piece of machinery with different colored wires sticking out of it whichhe got out of the dumpster at Western Union. He also had some uneaten food on his cart:a donut, a sandwich (on whole wheat bread) still in its wrapper, and an individual-sizedbox of raisin-bran cereal. When I asked if he was going to eat the raisin-bran, he wanted togive it to me, but I told him to keep it. “It looks good on the cart,” he said, which indicatesthat the cereal probably had a decorative purpose more than a functional one. He also hadhalf of what looked like a voided meal ticket from the Embassy residence. As he does withother collectibles, he had carefully covered the meal ticket with plastic and placed it on aconspicuous spot on top of his cart.

Bill told Dana on several occasions that “God Almighty” hadcommanded him to take up the “cart job,” a pursuit that provided theUnited States with added security and strength, protected women, helpedwith the construction of skyscrapers in downtown Los Angeles, and bywhich he could make “an honest living.” The last and most modest attributewas the one Bill mentioned most often. Prior to taking up this occupation,Bill reportedly led a life of crime and spent much of his adult life inprison for burglary or attempted burglary. That all changed, he reported,“When I started the cart job about ten years ago, I stopped all that stuff.Even shoplifting.” On another occasion he commented, “With this job . . .

I always stay honest. Strictly honesty and truthfulness.”One could dismiss all of this as the delusional enterprise of a crazy

old man, especially since his dedication to the cart job had some negativeconsequences. Bill was arrested once for hitting a woman who, he claimed,was rummaging through the objects in his cart. When a case manager fromthe community mental health clinic suggested moving into an apartment,Bill balked at the idea because he would not be able to negotiate the cart

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in a building without elevators. Yet, if one considers the meaning of hisbehavior and the content of his delusions one can just as easily imagine aman striving to make a decent place for himself in the world. Who knows?Given a different environment, Bill might have had the opportunity to puthis collecting and organizing skills to more productive purposes. Trappedin Skid Row, he did what he could.

Louise had an even more elaborate delusional system centered on work.The following account is culled from Dana’s fieldnotes.

Dana and Jackson first met Louise in July 1988, less than a week aftershe had become homeless. Louise had gotten into an argument over hermonthly allowance at the board-and-care home in which she resided. Sheclaimed (no doubt correctly) that the management was keeping her benefitschecks and giving nothing to her. So she left (or was told to leave) andmoved into an inexpensive motel – only to have her money stolen from herroom. With that, Louise became homeless and gravitated to downtown LosAngeles and Skid Row where, to make matters worse, her purse, with allof her identification, was stolen. New to homelessness and unaware of themissions and shelters, Louise slept on the streets. When Dana suppliedher with the names and addresses of two facilities in which she mightfind temporary housing, Louise took the information and, within a month,found temporary shelter and began the process of getting her SSI benefitsreinstated.12 This latter task took more than six months. As soon she wasback on the SSI roles, and had received all of the money owed to her, sherented an apartment.

Dana went to visit Louise in her new home. When Dana asked her outfor lunch, Louise declined on the grounds that she had been working down-town and was tired. Five days a week, she worked as a special governmentagent, checking prices on items in Grand Central Market on Broadway.But really, Louise went on, she was a doctor:

I’ve been practicing on the mentally ill and mentally retarded. They act so bad and it’s somuch pressure being a doctor; you tell them what to do and they don’t do it, and they sayyou caused their death and all that. A lot of pressure there. I’m a specialist. I’m a govern-ment doctor, but I’m in mentally retarded and mentally ill. I’ve always been interested inthe mentally ill.

Two months later, Louise reported she had been on vacation for a monthbecause she had been sick with the flu and also because she had injured herankle on the sharp metal edge of her bed frame. She told Dana that she wasplanning to return to work shortly. Two months later, however, her anklewas much worse, and Louise reported that she had not worked for threemonths. Nor had she been able to take part in her usual activities – churchservices, a women’s group, and shopping.

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I don’t do much of nothin’. I do a little shopping, but most of the time I’m home on accountof this leg. I’ve been wanting to go places. I’ve been to the May Company13 once, but Ididn’t get back for the sale because I was hurting so bad.

Louise’s health continued to deteriorate. Her ankle became so badlyinfected that she was hospitalized. Soon afterwards she spent much of twomonths in the hospital because of heart problems and high blood pressure.She became increasingly isolated and inactive. When Dana visited severalmonths later, Louise was withdrawn, emotionally flat, and distracted.When asked if she was planning to return to work as a secret federal agent,she replied that she had retired and was hoping to soon receive her pension.

Some months later, following her last visit to Louise, Dana wrote:

Louise has changed. . . . It’s a change I noted the last few times I saw her; she’s muchmore subdued, “depressed.” Gone is the garrulous, sociable person I knew when I first mether. More than this, though, she now seems more suspicious than before and is obviouslyhallucinating. She subvocalized throughout my short visit, doing so more loudly when weweren’t talking.

To maintain that Louise’s decline was due to worsening psychiatricand physical conditions might be accurate, but would miss the point. Hercommitment to her jobs as a government agent and as a doctor not onlyprovided her with a positive sense of self, it got her out of her apart-ment and downtown everyday, where she had opportunities to socialize.A fantasized life, perhaps, but real and satisfying routines whose loss shefelt profoundly. Her statement that she had been on vacation might beinterpreted as her attempt to come to terms with her physical limitations.Her forced retirement and waiting for her pension spoke eloquently of herdistress at having her life so curtailed. Isolated, ill, and without support, itis unlikely that Louise ever had the opportunity to re-establish routines inwhich she found purpose and meaningful human contact.

CONCLUSIONS

In his Foreword to Robert Edgerton’s Cloak of Competence (1967), anethnography of the lives of mentally retarded persons, Walter Goldschmidtwrote:

The major impact of this ethnography, as it is with all ethnographies that reach deep intohuman motivation, is: how like us they are after all. They are like us in their diversity aswell as their similarities; above all, however, they are like us in their desires to be human,and to be seen as human; in this their humanity appears in all its nakedness (1967: xi).

I hope that the same might be said of this ethnography of the lives ofhomeless mentally ill persons in the Skid Row district of Los Angeles.

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While it is true that the AHMI informants clearly suffered from severemental illness, a view of them that focuses exclusively on pathology doesthem an injustice (Koegel 1992). One has a choice in how to approachtheir fantasies and phantasm. There is the clinical perspective that reducesthem to symptoms of psychopathology, important only as markers toward adiagnosis. Or, one may see the fictions as representing behaviors by whichindividuals sought to infuse their lives with meaning and to present positiveself-images to themselves and others. In this latter, humanistic view, thatthe contents of their presentations were fantastic and delusional was notof prime importance. Of far greater consequence was that their search formeaning and eventfulness was very much tailored of the same materialfrom which all of us seek to fashion our lives. The need of informants toappear busy, successful, and independent were not symptomatic of severemental illness. Their illusions of being influential or being connected toimportant people was not categorically different from what many of usdo. Indeed, their search for meaning through the creation of eventfulnessbears a close resemblance to Anthony Giddens’s (1991) reflection on theformation of self-identity in the age of modernity. First, his notion thatthe traits which form identities vary socially and culturally is substanti-ated by the attempts of the AHMI informants to appear busy, normal, andengaged with larger projects – all very much characteristics of present dayAmerican society. Second, that the AHMI informants use delusions to giveform to their presentations of self is not so different from Giddens’s (1991:52) assertion that self-identity is “created and sustained in the reflexiveactivities of the individual.”

We must not discount the need that all persons have to create meaning,nor think that those with severe mental illness are not concerned withexpectations about what they are doing, or have already done, with theirlives. Dean, the auto mechanic, himself 49 years old at the time, once spokeof this. The following are Tom’s fieldnotes about what Dean said.

He talked a lot about mid-life crisis. Dean said, “It’ll eat you alive if you can’t vent it. Thedreams before 40 are no longer dreams after 40.” They come closer to reality, he said. Ifyou have no future after 50, you’re gonna be what you are, no progression, then you go intodepression, a mid-life crisis. You turn on your family. “I’ve seen it over and over again,”he said. You need progress in life or you become more “serious, more severe.” You need achange.

From this perspective, the worst aspect of life in Skid Row was not theviolence, normative substance use, or grinding poverty. Its worst attributewas that it prevented individuals from having the opportunity to createmeaningful lives out of sustainable routines. When Bill, the man with thecart job, lost his regular sleeping place by the old Western Union Building,

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he wandered the streets at night in fear that if he slept he would beattacked by “street walkers” and criminals – a fear that was not unjustified.Roosevelt was once arrested, just a few yards from the entrance to a shelterfor mentally ill homeless people, for buying crack from an undercoverpolice officer. Dean never did find a job as an auto mechanic and wentinto a sharp decline. For all of his fabulous accounts, William knew hewas dying of AIDS. Don, the man who demanded that I not dismiss himas insane, once said that he felt as though he was “surrounded by horror,”a statement that was stunning in its ability to convey, I thought, the all-encompassing reality of Skid Row’s filth, madness, poverty, disease, anddanger. But when I asked Don to tell me what he meant, his reply stunnedme again. For him, the horror was not so much the physical realities anddangers of life on Skid Row. The horror, he explained, was that he feltalone and had no one with whom to talk. On another occasion, Don pointedto a group of junkies and said he did not want to become “one of them.”Yet, he did. Eventually, the horrors of Skid Row in combination with theeasy availability of crack drove Don into addiction and out of a shelter thathad served as his refuge for more than 5 years.

It would be a mistake to regard the delusional nature of informants’fantasies as indicative of nothing more than pathology. The meanings oftheir delusions are far more important to consider. With no positive, cultur-ally constructed pathways, their search for meaning necessarily followeddelusions, fantasy, or self-destructive behavior. Yet, is this so different inkind from what anyone does? Self-destructive behavior is not unique to theseverely mental ill. The construction of eventfulness is found everywherein our culture. All of us pursue occupations or careers, inhabit culturalniches that provide the meaning and purpose that are so essential to humanexistence (Goldschmidt 1990). Along the way, imperfection, fragility, andfailure inevitably bring all of us to seek to mantle ourselves, to a greateror lesser degree, in a cloak of competence (Edgerton 1967). We invoke thethings we have done, the people we have known, the places we have been,to assure ourselves and to convince others that our lives are important andmeaningful. I would maintain that if there were significance in the inform-ants’ pursuit of eventfulness it was in the familiarity, not the strangenessof their fantasies. In my experiences with homeless mentally ill personsI have found, like Harry Stack Sullivan (1953: 16) that “we are all muchmore simply human than otherwise, be we happy and successful, contentedand detached, miserable and mentally disordered. . . .” And it is this famili-arity that challenges the notion of the fundamental otherness of severelymentally ill persons. Only delusions about the unique place “normal”people occupy in the cognitive universe keeps us from recognizing this.

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NOTES

1. Pseudonyms are used for all informants. The same pseudonyms were used in previousarticles (Koegel 1992; Cohen and Koegel 1996).

2. Robert Desjarlais (1994), in his sensitive ethnography of homeless mentally ill personsin a Boston shelter, takes a somewhat different approach. He maintains that the circum-stances of their lives and their severe mental illness make their experience of theworld fundamentally different from the experience of individuals who are not severelymentally ill.

3. The Adaptation of the Homeless Mentally Ill study was funded by a grant from theCalifornia State Department of Mental Health (Contract No. 90-70044) to the Depart-ment of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles,Paul Koegel, Ph.D. principal investigator. The anthropologists who conducted fieldwork were: Dana Baldwin, Ph.D., Jackson Underwood, Ph.D., Thomas Ward, Ph.D.,Paul and myself. At the end of the project, Paul gave me copies of everyone’s fieldnotesso that I could give a thorough account of our work in my Ph.D. dissertation (Cohen1993). In writing this paper, I have, again, relied on these fieldnotes.

4. The question of how our participation in the lives of informants might have influencedour observations has been raised a number of times following presentations I havemade. Indeed, it was a matter that concerned me at the time of the research. Until, thatis, I discussed it with Paul Koegel who noted that it was unlikely that our presence,at most a few hours per week or month with any one informant, had a significantinfluence on the course of their lives – and whatever influence we might have had wasmade insignificant by the circumstances of life in Skid Row and the influence of severemental illness. In looking back, it is obvious that our presence had little or no effect. Iwish that it had.

5. During one of these appointments, the psychiatrist, because of a bad back, conducteda psychiatric evaluation while he lay on a couch and the informant sat in a chair.Tom, with some amazement, noted the reversal of roles in this odd pantomime ofpsychoanalysis.

6. Graffam and Turner identified eight types of eventfulness: vicarious (“personalizingevents in another person’s life”); prolonged (attaching “immediate significance to anevent somewhat removed from the present”); exaggerated (“elevating mundane eventsto a more profound level of experience”); actual problems (real, even profound, prob-lems may be used to elicit attention and support from others and thus raise levelsof eventfulness); normalcy fabrications (assertions of a “normal” existence); fantasyidentification (“taking on the identity of various movie or television actors or charac-ters with no admission of pretense”); fantasy entertainment (use of fantasy as a “validand valuable activity in everyday life”); and idealistic expectations (“belief in a morenormal existence in the future”).

7. The legal battles were real, if quixotic. William had, in fact, filed a number of law suitsagainst his various persecutors in the city government, but all of the suits had beendismissed summarily as being frivolous.

8. Rapid Transit District of Los Angeles.9. An idealistic expectation. See note 6.

10. This might have been a reaction to the AHMI researchers, all of whom were identifiedas being associated with UCLA.

11. Many of his entries consisted of long lists of visual hallucinations: “A glimpse of acow, a glimpse of a woman. . . .”

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12. Apparently, the board-and-care home had continued to draw on Louise’s bank accountand did so until the Social Security Administration discovered that she was no longerliving there and canceled her benefits.

13. A large department store in Los Angeles.

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Department of Social MedicineHarvard Medical SchoolBoston