There’s a guy I see every time I go to work. He sits on the sidewalk right next to the newsstand. Always in that same spot. His hair is dreadlocked and dirty and he’s often quietly muttering to himself. A few decades ago, if you would have asked a bunch of experts what they think this person needs – like, what is the best way to help him – the answers you would have gotten would be really different than the ones you’d get now. And that shift in thinking, it’s at least partly because of this guy — 

     Sam: Alright. Hey, Katie. Carla’s here. She’s got the microphone.

That’s Sam Tsemberis with producer Carla Green who we sent to record him.

     Carla: Okay, yeah. Just tell me what you had for breakfast this morning…

     Sam: Tell you what? 

     Carla: What you had… what you had for breakfast- 

     Sam: What I had for breakfast? This morning? So I’ve been eating bagels for breakfast for the last three days.

     Carla: Ok… I think, I think…

     Sam: So did I pass? I mean, is that ok? [LAUGHS] What if it was scrambled eggs – it’s like no! Is there a right answer? 

Sam is a psychologist, who, back in the 1980s was working with homeless people in New York City. And the ideas that came out of the work he was doing are pretty foundational to how people think about solving homelessness today. 

Back then, Sam’s typical day was spent driving around the streets of New York in a van with a nurse and a psychiatrist – essentially making sidewalk house calls to the city’s homeless.

     Sam: Two or three of us would be in the van with the driver and we would receive referrals. All kinds of people would call and say, I have… uh, I want to refer somebody to you. I saw them on the corner of 65th and Park, they’re ranting, and they don’t look well at all. And they’re standing out in the middle of the traffic trying to convert the drivers into some belief system.

The 1980s was really the beginning of homelessness as we now know it. Mainly because of rising income inequality and the dismantling of a lot of social programs like public housing. The crack epidemic and deinstitutionalization certainly didn’t help matters either. Anyway, homelessness was particularly exploding in New York. And there was a feeling that some of the people on the streets might be a danger to themselves or to others.

     Sam: And if they met that criteria, we would bring them to the hospital. Voluntarily, if we could accomplish that — persuade them to go. Or involuntarily, if necessary — we would call the police and they would be taken sometimes in handcuffs to the Bellevue psychiatric emergency room.

Sam thought there were times when involuntary commitment was necessary, but he was never completely comfortable with it. Sam had ended up in New York City for grad school where he’d gotten interested in the psychiatric survivors movement. The movement challenged the traditional paternalism of psychiatry and promoted the idea that patients should control their own care. This was the future Sam wanted. Which put him at odds, sometimes, with his co-workers. 

     Sam: We ended up in Grand Central Station one night. 

The team was responding to a call about a homeless person that they referred to as “the Catwoman.”

     Sam: …because she loved cats. And when she was outside, she’d have a cat sometimes with her. She always wore black, completely black outfits. And she was in the bathroom – the women’s bathroom – of Grand Central Station where she would stay. And she was like, “Leave me alone. I hate you people.” They thought, oh she’s in denial of her, you know, desperate situation. She’s not safe. So they bring her to the hospital. I was very upset by that.

This was not a situation Sam thought called for involuntary commitment and so he made an anonymous call to the legal aid program in the hospital. 

     Sam: I said, I just… I don’t want to say who I am. I just want to tell you about a situation that’s in the hospital right now. There’s this woman that was hospitalized involuntarily. I think she needs representation. She wants to be out of the hospital. 

This was an early sign that Sam was generally on team patient over team psychiatrist. Still, he worked like this for a couple more years. Driving around the city, checking in on people, sometimes taking people to Bellevue.

     Sam: We took about 300 people a year to Bellevue, like one a day, you know, on average. And at the end of the year, when I was doing follow-up studies like what happened to these people, many of them, like two-thirds, would simply be returning to the streets. And so there was like an awareness that whatever this is, whatever we’re trying to do with this population is not working. It’s not working. 

This is According to Need, Chapter 3.

After a couple years of this routine – taking people to Bellevue, seeing them bounce back onto the streets, Sam decided to try something new. Instead of dragging people off to the hospital or a kind of here’s-your-diagnosis-and-here’s-your-prescription methodology, Sam wanted to try basically just asking people how he could help.