Jeremy and the American Dream

What are some of the founding beliefs of the United States? Or at least the current ideas that we purport as the foundations of this nation?

The two most prevalent words in the "American" language would most assuredly be freedom and equality, concepts built upon a foundation of the Puritan work ethic¹. If we are free we can work, if we are equal we all have the same opportunity to work, and stemming from the Puritan work ethic we seek to work to assure ourselves we are one of the "blessed." The maturation of these two concepts throughout our history and culture along with the Puritan work ethic birthed the "American Dream."

What is the American Dream? Here at Xavier we have an entire center, The Center for the Study of the American Dream, dedicated to studying and understanding this cultural phenomenon. Although the various forms and methods to achieve the American Dream have changed over the years, astoundingly, it does not seem to have ideologically changed much at all.

Today, most people would describe a picture of a husband, wife, 2.5 children, and dog named Spot standing next to a medium sized house with a white picket fence to encapsulate the ideology behind the American Dream. What does that picture represent? Does it represent the better life that countless immigrants are searching for as they walk, climb, and swim toward the United States? Is it the idea that some US citizens hold in their minds to push them through another day of an excruciatingly meaningless job? Is it the picture of what the poor and poverty-stricken have failed to achieve in their lives? Is it even what the majority of Americans really want?

 John Steinbeck

One of the most influential and ingrained beliefs within this nation is that each citizen will move up the socioeconomic ladder proportionally to his or her own volition. This belief facilitates the existence and encouragement of the American Dream. In fact John Steinbeck brought attention to this idea when he said,

“Socialism never took root in America because the poor see themselves not as an exploited proletariat but as temporarily embarrassed millionaires.”

He explains that the poor within this country are taught and told that it is solely their fault that they did not achieve the American Dream. It was the poor who put themselves in poverty and it is up to them to pull themselves up by their bootstraps. When they fail to do this, it is their burden to bear and their failure to endure. The poor are poor by choice - past choices, current choices, and nothing else.

Is this true? Whether it is true or not can be debated on another day, what is important is that Jeremy (see posts 1, 2, and 3) is living within this belief system and living his life by the bible of the American Dream. This is specifically relevant on several fronts within his occupational performance.

On several occasions Jeremy has expressed severe self-deprecation by making statements such as, "I am not worth anythin' anyway, I am just here rotting on the side o' this big ol' city" or "I belong out here. I am a screw up, that's pretty obvious don't you think." Jeremy describes his experience of panhandling in Cincinnati,

"I keep my head down and they do the same. They walk by without paying much attention to the bum sittin' on the side of the street. If I have a good sign or something then maybe one will throw a couple coins my way, but most the time I think that is more for them than it is for me. Feels good to give a lil' charity to the less blessed you know."

 Here in the US, homeless people are beaten, taunted, and left to die on the side of the street.  A homeless person is first homeless, then a person, dehumanized and forgotten as a failure within our society. We tell our children not to make eye contact, as we ourselves avert our glance. We try to ignore as long as possible as a homeless individual approaches us on the streets asking for money. We are afraid of the possible "crazies" out there, because only a crazy person would allow themselves to remain on the streets for years, months, or even days.
But interestingly, the first sort of community service most often suggested is "serving at a soup kitchen". What is it about this activity that is so appealing to those who have privilege? How is it that a society that casts out its poverty-stricken will so readily pass food across the counter to a homeless person for a night? The answer to this question, personally, comes from my own experiences in soup kitchens and visiting the people on the streets of Cincinnati: fear.

The fear within us towards the homeless is planted from the very first time our parents hold our hand a bit tighter as we walk past a man stooped on the corner of a city square. Fear germinates as we watch cartoons and television shows that depict homeless people as dangerous and psychologically unstable. Fear branches into indignation as we watch homeless men and women walk into rehabilitation programs and human service agencies while we work jobs and go to college to earn our dreams. Fear blossoms into hatred and sometimes violence as we pull ourselves far away from the idea that those people could possibly be the same as us. Finally, the fruit of fear is plucked as we stand behind the protective barrier of a soup counter and hesitantly pass a plate of food to the homeless. We neither have to speak nor touch, both of which will remind us of their humanity. If they are not human, a person just like me, then there is no chance that I, who have worked so hard, could lose my precious American Dream. This is why we, or at least I, glanced away from our brothers and sisters on the streets but scurried to a soup kitchen to provide them with food. Standing behind a plentiful counter of food, serving those who had less without actually interacting with them solidified my belief that they need not be treated like humans.

Non-human. This is what the culture Jeremy is surrounded by tells him that he is: anything but success and anything but human. He feels he is not capable nor worth being anything but homeless. He fought for a country that now is afraid of him.

______ ______

It is this culture and these factors that you, as an occupational therapist, must take into account when working with Jeremy. You must understand that although your goal for him may be to adequately provide a roof and living for himself, there are more obstacles than simply motivation to overcome.  Is there a place for him to go in Cincinnati? Will his mental condition allow him to work in any setting, let alone a traditional one? Can he overcome the culture that surrounds him on a national level without the support of a community that rejects that culture? These are the questions occupational therapists must discover through analyzing the context and specific situation of their clients. We are a holistic profession which means we not only look at the whole person, rather it means we also look at the whole picture.

¹ Cullen, Jim. The American Dream: A Short History of an Idea That Shaped a Nation. New York: Oxford University Press, 2003. Print. 

Final two photos are from Robin Cheers's Everyday People Series

Jeremy and Post Traumatic Stress Disorder

Today there are countless veterans living with PTSD who have returned from wartime situations and are attempting to acclimate to the civilian lifestyle. Many of these also populate the streets of the cities of our nation. Veterans represent 23% of the homeless population in the United States. 96% of homeless veterans are male. There were reported 192 sheltered and unsheltered veterans in Cincinnati/Hamilton area in January of 2011.

What do veterans with PTSD face when coming back to the United States, let alone when they are homeless?

First, the direct symptoms of PTSD are burdensome and affect an individual immensely. The Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition- Text Revision) provides descriptions of the symptoms one must present with to be diagnosed with PTSD:

There is persistent reexperiencing of the traumatic event in memories, images, emotions, thoughts (Criterion B1), dreams (Criterion B2), acting or feeling as if the event is actually happening again (Criterion B3), intense psychological distress at exposure to cues that may be relevant to the experience (Criterion B4), or physiological distress to the same cues (Criterion B5).

The individual must also persistently avoid those stimuli associated with the trauma and they will experience numbing of general responsiveness that had not appeared before the traumatic event. This symptom can manifest as efforts to avoid mental processed associated with the trauma as in thoughts, feelings, and conversations (Criterion C1), efforts to avoid concrete items like people, places, or activities that remind the individual of the trauma (Criterion C2), an inability to remember or recollect a significant portion of the trauma (Criterion C3), disinterest or less interest in common activities enjoyed before the trauma (Criterion C4), antisocial behavior or feelings of detachment or estrangement from others (Criterion C5), a general restriction of emotions (Criterion C6), or a belief that they will not have a full lifespan or will not complete major life goals (Criterion C7) (DSM–IV–TR).

Often times, flashbacks are caused by this intense aversion to threat or danger, and can play a significant role in maintaining this symptom by constantly reminding the survivor of the danger or threat. This creates a vicious cycle, from which it is difficult for the survivor to remove him or herself (Brewin, p. 185).

Finally, there must be a state of increased arousal which can emerge as difficulty falling or staying asleep (Criterion D1), angry outbursts or general irritability (Criterion D2), difficulty focusing or concentrating (Criterion D3), hypervigilance (Criterion D4), or an exaggerated startle response. These symptoms, after the traumatic event, must be present in the individual for over a month to be considered PTSD (Criterion E); acute PTSD is diagnosed when the symptoms are present less than three months, while chronic PTSD lasts longer than the three month period. These symptoms must also cause significant distress and disorder within the normal functioning of the individual through any important aspect of their life (Criterion F) (DSM—IV—TR).

These though, are simply the fundamentals of the disorder; the dynamic condition of PTSD can influence varying people in varying manners, creating large varieties of manifestations that could be considered within the PTSD spectrum. Many soldiers, returning from and with a war torn experience who show symptoms of PTSD, seem to have some trends in their reentry experience.

These symptoms create many obstacles for returning veterans and often lead to outcomes that severely affect their everyday lives.  Jeremy's experiences with these obstacles ultimately had a strong influence in facilitating his current situation.

If you have not already, I would recommend reading these two (1) (2) posts so that you know who the fictional character Jeremy is and why I am talking about him.

When Jeremy returned from war, his parents used to tell him that he seemed "changed". He was less enthusiastic about the activities he once enjoyed: motorbikes, fast cars, and ATVs. He often avoided driving in general and refused to drive on highways or other long stretches of road without exits because this was a factor that had caused the tragedy that occurred overseas. He had told his parents that he wanted to stay in Cincinnati for the job opportunities and cheaper rent, but he alluded to being uncomfortable with driving the distance to return home as well.

He became distant and irritable with his family first and then generally everyone around him, he began to calm his anxiety and penetrating headaches with copious amounts of alcohol. His personal relationships disintegrated along with his perception of his personal worth. He was conflicted in his identity because his personal worldview and moral system did not coordinate well with the things that had occurred during combat. His most overwhelming guilt came from surviving the tragedy that killed the three other members in the vehicle, because he had been the one driving. He felt like he had no control over his life anymore and that he was not capable of functioning properly. The combination of these factors led him to, as was described before, lose his job and ultimately facilitate his chronic homelessness.

Once Jeremy first became homeless, his PTSD was in many ways exacerbated by the environment in which he was living. His already hyper-vigilant mind and frequent bouts of paranoia preventing him from sleeping. With each attack from other homeless people or simply inhumane citizens, more experiences began to fill the memory banks to which his mind would flashback. His temper was uncontrollable and his emotions were even more sporadic. With every honk of a horn or screech of tires, Jeremy would be thrown into a panic attack or flood of anger. This continued until he found his camp near the river, where he was able to leave the populated areas of the city.

Over the next few years, Jeremy was able to remedy some of the severity of the PTSD symptoms by creating some structure in his life. He has specific places within his camp for certain activities, while not always enforced they are still considered important. He continuously works to construct a more elaborate and luxurious structure for his cats to live in, while only sometimes improving his own. He is mostly consistent in waking up early in the morning and walking to find work in downtown.

At this point Jeremy refuses to drive, is very skeptical of anyone who enters his camp, avoids large social situation unless absolutely necessary, and spends most of his time alone. When he is social he says little and listens less, only freely interacting with Will and Terry. He often reports that he is awoken from sleeping by nightmares and flashbacks which leave him in an alerted anxiety preventing him from sleeping well.

He believes the system he has created is the only solution to the way he feels and stubbornly argues with anyone who believes he could live in society in a more traditional manner. He has begun to exhibit a sense of pride in the new life that he lives day by day, with nothing and no one other than himself on which to depend. However, on many occasions he expresses strong self-deprecation and shame due to his homelessness and mental status.

His sentements are well put in his quote "Who would want to help a lazy, crazy bum like me anyway? We're all lookin' out for number one here aren't we. That's what I'm doin'... lookin' out for numero uno."

References:
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
 (4th ed., text rev.). Washington, DC: Author.

Brewin, C. R. (2003). Post traumatic stress disorder: Malady or myth?. New Haven: Yale Unniversity Press.

Paulson, D. S., & Krippner, S. (2007). Haunted by combat: Understanding PTSD in war veterans including women, reservists, and those coming back from Iraq. Westport, Connecticut: Praeger Security International.