The current issue of The New Yorker features an article by Malcolm Gladwell on the problem of the homeless. The title of “Million Dollar Murray” sets the theme: It may be a lot more expensive to manage homelessness than it is to solve the problem. Murray Barr was a homeless person in Reno, Nevada, until he died recently of intestinal bleeding attributed to his alcoholism. If all of the free medical care that Murray received over the years, and all of the time spent by police and ambulance teams picking him up for emergency medical services were added up, he may very well have had the highest total in medical services since Howard Hughes decided to take up residence in Nevada–quite possibly reaching a total of $1M.

And yet there was a time not long ago when Murray was successfully placed in a job, and he was staying sober. Some time later–he had accumulated some $6,000 in personal savings by that time–he was terminated out of the program in an act of bureaucratic necessity, and immediately resumed his prior street life, which then proceeded to cost the State ten to a hundred times as much as it had been costing to maintain him in sobriety and usefulness.

Issues such as these have never been about cost-benefit considerations. The State must act with an even hand, and the problem of homelessness is simply too large for a policy of actually solving the problem one homeless person at a time to be extended to all. I have been wrestling with this issue for a while, as our new mayor is out looking for a remedy.

I had been thinking of a neurofeedback program, with the services delivered through the same agencies that are currently working with the homeless, to address the mental health problems that afflict much of the homeless population. But the numbers are staggering. With an estimated 90,000 homeless in Los Angeles, even a program that cost only $1,000 per person would mean a budget line item somewhere of at least $100M. No wonder nothing happens. Numbers like that just weaken anyone’s resolve.

The key insight that Gladwell brings to bear in his article is that the homeless population is in fact wildly inhomogeneous, and the ones among them who cost the State a lot of money are actually relatively small in number. That of course makes all the difference. Most homeless people are just passing through, as they typically succeed in getting their life back together. Most do so sooner rather than later. The persistent problem of homelessness is much smaller, and the ones who combine mental illness with addiction, and eventually with major medical ailments, is smaller still.

Of course it would make sense to do what we can to abort the slide into full dependency over the entire distribution, but that prospect is just too daunting for the policy makers. Perhaps the realistic objective would be to salvage the ones who are costing the State a lot of money on a regular basis, the Murray Barr’s of this world. The payoff on progress here would then lead to propagating the work to a larger population.

There is precedent here. George Fuller ran a biofeedback pilot or demonstration program in San Francisco years ago, and it was very successful. We also have the example of the stunningly successful program down in Houston with the crack addicts, where more comprehensive services are offered around the neurofeedback. Our own research project on addictions, recently published, also depended on embedding neurofeedback in a supportive social context that would be ongoing. Those who succeeded in the program were those who were able to sustain a minimum level of social connectedness.

From this encouraging past history with biofeedback and neurofeedback, two possible strategies emerge: The program for the crack addicts in Houston is a model for the intensive care that would be needed for the Murray Barr’s of this world. Here a whole host of services need to be provided to get the addict back into productive life. The program would be high-cost per capita, but with the promise of a high return, as is being proved out in that program.

And then there is the whole rest of the distribution of the homeless, for whom an expensive, labor-intensive intervention would be out of the question in our political and fiscal environment. Something very different is needed.

A number of years ago the Los Angeles Times Sunday Magazine featured an article about a homeless person who had been taken on as a project by a local dentist. The fellow got a mouthful of new teeth. He received new clothes, and there were now a number of people interested in his welfare. But eventually he fell back into homelessness. More recently, a feature writer for the Los Angeles Times has taken up the cause of a homeless musician, a man who once studied at Juilliard. He had since succumbed to schizophrenia. He still plays his cello on the street. These people are not violent. They don’t attract a lot of attention from police, nor do they frequent the emergency room. They are just not quite in a position to put together a productive life.

In both of these instances, the missing component of care was neurofeedback. Schizophrenia does not yield to the will. It does yield to brain training, and to peripheral biofeedback as well. The problem of mental illness here is well acknowledged. The difficulty is that these folks will not by and large seek out the mental health services that are offered, or to persist in medication regimens that are prescribed. A standard mental health treatment model fails these people consistently.

Given that discouraging history, how might one construct a successful neurofeedback program? The first necessity may be to distance it from the usual mental health context. It could, for example, be presented essentially as entertainment. It should be made available right where these folks congregate. People might even be paid to do the neurofeedback. Once they start feeling better, sleeping better, and having fewer drug cravings, the word will spread among the homeless all by itself, and neurofeedback may come to be the thing to do to while away some hours of boredom.

The obvious paradigm for such a program is the “non-prescriptive” feedback approach such as is offered by NeuroCarePro. One would not expect to solve all the mental health problems at this first step. The program should be regarded as a portal of entry in which the person takes the first voluntary steps toward self-care in the area of mental health. But after succeeding here, the person at risk may well be ushered successfully into more intensive and targeted interventions.

This entry was posted on Wednesday, February 22nd, 2006 at 1:52 am and is filed under Application of Neurofeedback, Outreach. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.