Illustration: Jonathan Bartlett

Prescription for a Homeless Man

A physician finds a way out of the woods.

Stanford Magazine
Mar 24, 2017 · 15 min read

BY LOREN MELL, ’96

Recently I took a Monday off work, my third sick day in eight years. When I returned the next day, I was surprised nobody asked what happened. Perhaps they were respecting my privacy or assumed ’tis the season for the flu. But if they had asked, I would have told them the truth: I felt depressed.

As you might guess, my mood had to do with the election. I had become mired in Facebook quicksand, exchanging rants about the electoral college system. I felt that Clinton failed to connect with heartland voters, to give voice to their perspective. My opponent opined that his vote was not being assigned equal value. While pondering whether both were true, I realized that my views reflected something I was feeling about myself.

The week prior, I had endured a lengthy after-hours meeting about faculty compensation, which left me contemplating the vicissitudes of labor market forces. I am a radiation oncologist, which is someone who uses radiotherapy to treat cancer (and other less imperial maladies). After years of hard work, I make a lot of money. Sitting in a room of rich people quibbling about their incomes was unsettling, tempered only by a vague sense of entitlement to what the market will bear. I have loans to repay, a mortgage and kids to put through college. Yet, I have a beautiful house and a beautiful wife and 2.4 beautiful children (counting dogs as 0.2) and live in America’s finest city, and like that song goes, I found myself asking how I got here — by which I mean not achieving such great heights, but feeling so low about them.

Economists describe the waning power of money to buy happiness as its diminishing marginal utility — meaning as you make more, you need ever more income to increase your satisfaction. Though the point of surfeit is different for everyone, the altitudes to which it can reach continually amaze me. Thrill depends on the danger that you might fail, yet I suspect my own children will never enjoy certain manifestations of it, their chief struggle this past Christmas being to list things they wanted that they didn’t already have. This might be the point of all that hard work, yet I wonder if something has been lost as a result — namely tethers. It is difficult to maintain perspective when one is constantly trying to obtain a better view.

Whether from a sense of duty or simple generosity, our family decided to donate gifts to a local family this past Christmas, through a program organized by our church. A charitable gesture that didn’t require us to move too far from the sofa. The anonymity of it, however, left me starving for a tangible connection. So I took my eldest son somewhere we hadn’t been in a long time. We went to visit a homeless man.

My discomfort with money undoubtedly stems from the blessings and burdens of my childhood. I was raised in a “glass castle,” broken and beset by numerous emotional and self-inflicted hardships. My parents divorced when I was 10, their tensions culminating in a heated argument at my birthday party. I remained in Oregon with my mother, while my father moved away to attend seminary. My mother and stepfather ran a small publishing company, but their real work began after hours, holding seminars and séances inspired by Jane Roberts’s The Seth Material. My mother channeled a spirit, Myriad, who advanced the central premise that you create your own reality, a path to achieve abundance, or spiritual wealth.

Illustration: Jonathan Bartlett

At times, it seemed my parents’ mission was to eschew material success, as though seeking it were a moral failing. During high school, upon returning from a retreat, my parents abruptly sold their failing business, auctioned our belongings, and packed my siblings, me and two of our cats (the others were left to their fates) into our red 1970 Volkswagen van, relocating us to a ranch in Lone Pine, Calif., operated by one Richard Moss, MD, promoter of consciousness and unconditional love. As a child, however, it was impossible to reconcile my parents’ metaphysical enlightenment with their chronic marital disharmony and psychological turbulence. The realities of translating New Age principles into complex human relationships would prove unstable.

One day several years later, I met a Navajo man who was volunteering at my father’s church. He expressed admiration for a hideous lavender silk shirt I was wearing. The thought occurred to me that I should just give it to him. I should have. It would have been a radical act of spontaneous generosity. I didn’t even like the shirt, but that didn’t mean I was indifferent to giving it away. What stopped me? The bother. The sense that it was mine. I always regretted that missed opportunity. I literally could not give this poor man the shirt off my back, instead condemning it to hang idly ever after in my closet.

It is December 29. The man we meet lives in a one-man tent in Discovery Park, northwest of downtown Seattle. I call him Burnside.

He wears a cheap, light blue zip-up sweatshirt over a faded cobalt Beatles T-shirt, aging Levis and a pair of black Vans. His curly blond hair is retracted in a ponytail, hanging to the tips of his scapulae beneath an oatmeal-colored wool hat. Standing 6-foot-1, his sallow face is cracked and weathered, with an uneven beard and a deep green-eyed stare peering out of sunken cheeks, revealing he has lived many more than his 40 chronological years would indicate. Sporadic sleeping habits and somnambulations have granted him a cumulative excess of 20,000 waking hours relative to a typical person his age. He fidgets like a man who has not had restorative slumber in a decade. He hasn’t changed his socks in three days. Imagining what it is like to walk a mile in those wet socks makes me shiver.

He is in desperate need of getting clean, literally and figuratively. A haircut would be hygienic as well as symbolic. In his lifetime, he has abused a wide array of legal and illegal drugs: tobacco, alcohol, marijuana, psilocybin, LSD, cocaine and, lately, methamphetamines. He has been homeless for nine months, ever since his sister reluctantly evicted him from her guest room, and off crystal meth the last three of them. Prior to that, he had an information technology job, but was fired for falling asleep at work.

Now he moves furniture and stacks boxes whenever day labor is available. He makes $70 to $100 per day, but it is inconsistent. A local food bank provides him nourishment, but he is frequently dehydrated. He receives financial support from his mother to pay for his cell phone, storage unit and Honda Civic, which doubles as his closet and refrigerator. She wonders if her helping him is helping him. A year ago, she paid for an inpatient rehab program with money she did not have. The day they released him, he relapsed. He had resolved to relapse weeks before then.

In this verdant and soggy corner of our country, Burnside has dug himself a deep and forested bed to lie in. Living in the park is not legal, but Burnside only obeys laws he considers just and sensible. According to him, he has squatter’s rights, and removing him from the park would require a 90-day eviction notice. (I have no idea if this is true.) His residence is a short walk from civilization, but away from paths and well-disguised. In it he runs a battery-powered space heater to stay warm, but this does not make it cozy. Though his presence disturbs no one, he is disturbed often: by day, raccoons; by night, enormous black spiders.

Seattle provides alternative — and one might think better — housing options. Burnside recently vacated a tent city he inhabited for six months, to seek solitude, security and refuge from the elements. The “city” occupies a quarter block on a graveled lot in Ballard. Burnside had lived there long enough to attain an encroaching level of authority and permanence that concerned him, a signal that it was time to go.

The way Burnside allocates dwindling resources when stripped of virtually everything is a testimony to the prioritization of basic needs. For what is he willing to tolerate arachnids, vermin, cold and uneven ground? A cell phone: communication. A car: mobility. Storage: hoarding. It is other people’s money, yet one could envision exchanging those same dollars for something with a roof, or selling whatever he is storing and not using. But he is intent on leaving the park soon and will need his cookware, furniture and heirlooms with unquantifiable sentimental value. I have frequently thought, given the choice, wouldn’t you at least want to be homeless in warmer climates? Burnside has this option, but there is something else keeping him in Seattle. His son, who lives with Burnside’s ex-wife, is about to graduate from high school.

Eyeballing him, I judge his health to be poor. Methamphetamines have claimed several upper molars. Tinea versicolor has turned the skin on his torso piebald. Sleeping in his car has precipitated bilateral leg swelling. He could have a life-threatening deep vein thrombus, or organ failure. As it turns out, it is only stasis dermatitis (broken skin capillaries from excess venous pressure) complicated by cellulitis, a skin infection. He needs antibiotics.

His psychiatric condition is perhaps his greater health problem. He vacillates in his sexual identity, describing himself as pansexual, which in itself is not problematic, but which he admits has led him into risky sexual encounters. He expresses concern he might have HIV. He experiences periods of high energy, decreased need for sleep, racing thoughts, and psychomotor agitation punctuated by episodes of writhing, floor-hugging depression, sufficient to cause social and occupational impairment. If you have ever read the Diagnostic and Statistical Manual of Mental Disorders or watched Homeland, you will recognize this constellation as Bipolar I. Yet the diagnosis requires that the symptoms not be due to a substance. I hang on the clause “due to.” Which is cause and which effect? Burnside self-medicates daily with a marijuana strain that is less euphoric but effective for his pain. I am unsure if the pain he means is physical or mental.

The more we converse, the more I realize how fascinating is the kaleidoscope through which he views the world. His speech is suffused with anger and self-loathing, despite a sincere concern for those even less fortunate than he. The passion he injects into frivolous anecdotes is humorous to the point of being enlightening. He delivered a vehement entomological defense of the unfairly maligned aphid against the cannibalistic ladybug (don’t get him started on moths vs. butterflies). Another thing he has going for him is insight, an underrated asset to anyone’s health. It is the flicker of light in the dark room of his existence. He identifies the harmful effects drugs have had on his life: divorce, unemployment, poverty, estrangement. He acknowledges the benefit of cognitive behavioral exercises he learned in rehab, which have helped him understand the relationship between his thoughts, his feelings and his behavior. Most of all, it has helped him identify his fears.

Burnside is scared of being happy, of feeling good, of succeeding. He is frightened of having money, because he knows his uncontrollable impulses will lead him to spend it in ways he does not want to. This fear has relegated him to solitude, because homelessness has as much to do with the loss of direction and purpose as it does with absence of shelter. The doctor in me wants to write him a prescription:

• D/C drugs
D/C alcohol
D/C tobacco
D/C risky behavior
Social work consult
Psych consult
Mood stabilizers
Sleep hygiene
Exercise
Family intervention

But it has been tried before.

Burnside’s downward spiral accelerated 12 years ago, when he nearly ended his life. He entered an inpatient rehab program and started taking divalproate, but quit because it short-circuited his emotions. If only he could have quit other drugs so readily. He recovered for a few years, then the patterns re-emerged.

“He is a great guy,” my teenager deduced, “who just makes horrible decisions.”

Now it is 40 degrees and rainy. In the morning, frost will cover his tent. His situation is desperate, beyond the prospect of living out the impending winter in this sylvan homestead, unemployed. At this moment, nothing makes me sadder than this perspicacious and caring man entombed in unrealized potential, knowing the many ways his book might have unfolded differently. You see, the reason I sought him out in particular is that he is my brother.

When we were kids, I used to tease him about the time when he was 8 and opened the gateway to our parents’ liquor cabinet to get smashed on whisky and rye. I nicknamed him BB, short for Burnside Bound, because Burnside is the street in Portland where all the bums live. My gift for prophecy. Now this gift plagues me with survivor’s guilt, for I am more than his keeper; I am his Corsican brother. What he experiences, I feel as it were my own. How do such similar circumstances of nature and nurture (there is no one on earth more similar) yield such divergent paths? Why after a hurricane do some regions rebound and thrive, while others lapse into abandonment? The roadside bomb of our childhood exploded, its shrapnel glancing off me and catching my brother in the chest. It seems random and unfair. I fantasize spending the night lying next to him, encircling him in my arms, telling him everything will be OK, the way I occasionally talk to certain patients.

YOUNG BROTHERS: Burnside and Loren. (Photo: Courtesy Loren Mell)

The wind picks up and the sky turns silver, threatening sleet. He gets in my car. We stop to get pizza, which he and his nephew gulp down voraciously.

I ask, “How many people fit in your tent?”

He has room for one.

Thinking back on Burnside’s briefly sustained recovery, one aspect stands out, making me wonder if something crucial was left off my prescription.

I weigh this as we drive to our sister’s house, where our mother also lives. My mother and I discuss ways to help Burnside find and finance housing. We try engaging him, but he seems woefully disinterested in this uncomfortable yet critical conversation. He steps outside to smoke. The desire to feel good right now is enormously powerful; he is a kindergartener who wants his marshmallow. Later, on our way home, I would ask my son what he thought about Burnside’s predicament.

“He is a great guy,” my teenager deduced, “who just makes horrible decisions.”

A fair one-sentence summary of his uncle.

Every doctor has patients like this, who won’t help themselves. Or can’t. The result is precisely the same. Burnside is a living paradox. He is the only person who can improve his situation, yet seems completely devoid of this capacity. Is it our choices that determine our greatness, or is it the situation? Or our choices given the situation? In this instance, it is a false dichotomy; the question doesn’t even make sense. He won’t because he can’t. He can’t because he won’t.

This of course leaves a different question: what should those who can and will do? It is the same thing we must do with all unsolvable problems — “cling to Faith beyond the forms of Faith,” believing that even if some of us won’t, the rest can. Energy can be defined as the ability to perform work, to translate a force over a given distance. But whence does this energy to force ourselves forward originate? I submit that it comes from the release of tension, which does not exist without contrast. Love thy brother, with an admixture of toughness and unconditionality.

It cannot be taken for granted that people know how to love themselves. I once saw my brother do it, when he was playing and recording folk music. His inspirations were the masters our father had strummed at campfire singalongs, long before our family dissolved: Phil Ochs, Bob Dylan, Gordon Lightfoot, John Denver. For Burnside, creating music was an organic mood stabilizer, attracting him as strongly as he would repel the synthetic ones he blamed for his mental castration, à la Don Quixote, Don Juan DeMarco or Randle McMurphy.

I once believed that progress could not occur in a polar system. Now I wonder if it is the only system from which progress can emanate. Perhaps addictions are no more fixed than ideas. Or it is possible to replace them with more fulfilling dependencies. Burnside is a musician, because in music he has felt the calming relief of self-expression. One last item to addend to my prescription: art therapy.

Bipolar disorder affects 4 percent of the population, but our whole nation suffers from it. It feels — and research suggests is — genetic. I sense the pull of its kid brother, cyclothymia. Usually my work makes me happy, despite the massive weight of people’s problems, because I know I did not cause them; my job is to help. Mostly I feel gratitude for the immovable goodness of people, despite confronting the oftentimes unstoppable force that is cancer. Other days I feel overwhelmed by the drudgery of adhering to ever-expanding regulations and managing trivial yet immortal complaints. In medicine, there is always more work to be done.

A recent study found a high correlation between physician depression and “burnout,” characterized by depersonalization, emotional exhaustion and a low sense of accomplishment — feelings prevalent in half of physicians. Other studies associate burnout with reduced empathy and empathy in turn with protection against burnout. So it would seem wise for doctors to embrace the notion of empathy. We recruit for it on admissions committees, cultivate it in classrooms. Doctors are taught the art of caring for the patient is caring about the patient. This stands to reason. Selfish people do not make great doctors, regardless of their competence.

Then, I read an article by Paul Bloom, “The Perils of Empathy,” which made me wonder if we’ve gotten it all wrong. Bloom laments the tendency for empathy to make us cling too strongly to our moral judgments, clouding our decision-making. First I dismissed it as semantic. Empathy, compassion: a distinction without a difference. Now I wonder if those who extol the virtues of empathy mean to promote compassion instead.

For even when governments, organizations and individuals are too rigid or bankrupt to enact goodwill, there are those whose daily focus is to champion grace and righteousness, no matter the personal toll it exacts.

Compassion is when I acknowledge the need to take a moment to hold a patient’s hand and listen. Within that space I can also politely cut them off when we have others waiting and work to do. Empathy is when I break down and sob in my office over the unbearable loss of a girl, the same age as my son, who was playing gymnastics on Saturday, went to the ER with a headache on Sunday, was diagnosed with medulloblastoma on Monday, started chemotherapy on Tuesday, radiation on Wednesday and died on Friday. I have empathy to thank for my crushing sorrow over a veteran whose lung cancer I failed to cure, whose funeral announcement I am reading, recounting his numerous heroic acts during World War II. Empathy is too paralyzing a burden to carry. It is an uncomfortable sentiment, with no obvious outlet. Compassion is what we should teach students; it is the more sustainable force.

Our natural response to discomfort is to surround ourselves with familiars who reinforce our beliefs, bogging us down in the predictable, vacuous conversations swirling around the social media toilet bowl. When the object is to win arguments rather than discern them, we cock the hammer one more notch. The political differences commensurate with my and my brother’s respective stations in life set the court for our tennis match, imparting each serve with greater velocity. Burnside feels that society has made a statement about him: There is no rest for the marginalized. Though this is his experience, it is not universal. For even when governments, organizations and individuals are too rigid or bankrupt to enact goodwill, there are those whose daily focus is to champion grace and righteousness, no matter the personal toll it exacts, a more catholic version of an underground railroad.

Then, something unexpected. As quickly as our conversation descended into vitriol, it evolves spontaneously, as if by punctuated equilibrium, into rhyme. The trolling morphs into a spitfire poetry slam, and I recognize, in its densely packed rhythms and inventive references, my brother’s singing once again.

In addition to the core anthropological needs, there is a basic human need for expression, which requires patience with each other and ourselves. A safe space includes latitude and even encouragement to explore erratic and confrontational ideas, to adopt irrational positions and behaviors, so people can examine them without being held as though they were immutable, insofar as they are truly mutable. We must allow people to be their own worst enemy, imagine that which is not real, procure coffee enemas, entertain conspiracy theories, cavort with alternate realities. We all need room to create and display art, to help us shed our idées fixes, beliefs that are mine, like that goddamn silk shirt I wish I had shed. Failure to do so degrades us the same as any addiction.

In defense of empathy, despite its perils, is that it — not compassion — drove me to visit my brother. Compassion allowed me to exit my comfort zone, but empathy created the zone in the first place, like a capacitor, storing energy before I could enter his domain and discharge it, grounding my electricity into the atmosphere. To those dreading the next four years, I offer this: Suffering is the greatest fodder for artistic expression. To Burnside, I say, echoing Tom Paxton’s lyrics,

Here’s to you, my ramblin’ boy
May all your rambles bring you joy


LOREN MELL, ’96, is director of the division of clinical and translational research in the department of radiation medicine and applied science at UC-San Diego.

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A Publication of the Stanford Alumni Association