Whose Category? Self-Naming, Dual Diagnosis, and the Career of “Triple-Challenged” by Wayne Martin Mellinger, Ph.D.

 Whose Category? Self-Naming, Dual Diagnosis, and the Career of “Triple-Challenged”

A Research Note

Wayne Martin Mellinger, Ph.D.

September 3, 2026

The Third System That Never Answered to a Chart

I did not experience my own crisis as three things happening to me. I experienced it as one thing: a mind coming apart in public, with nowhere private to let that happen. The people trying to help sorted what was happening to me into two familiar tracks almost immediately — psychiatric crisis, substance problem — because those were the two doors available to walk me through. What neither track could hold was the third fact that was, in practical terms, doing more to determine what happened to me than either diagnosis: whether I had a door of my own to close that night. Psychiatry could write orders. Addiction medicine could write orders. Neither could write me an apartment.

That is the gap I want to start from, because it is not abstract to me. Dual diagnosis, whatever its limits, was built by two systems that at least share a common object — the person as a bearer of clinical symptoms — and a common language for arguing about that person's inner state. Housing was never inside that conversation at all. It doesn't answer to a chart. It answers to a landlord, a waitlist, a program's behavioral-compliance rules, a market that has already decided what a unit costs and to whom it will be shown. When I was cycling through crisis, the psychiatric and addiction pieces of my situation were at least being discussed by people using overlapping vocabulary. The housing piece was being decided somewhere else entirely, by people who never saw the chart and wouldn't have known what to do with it if they had.

I have written elsewhere about reinterpreting that year through Joseph Campbell's hero's journey and archetypal figures like Dionysus and the wounded healer Chiron — madness read as a kind of initiation rather than pure pathology. I do not want to relitigate that reading here, and I do not want to romanticize what was, in real measure, dangerous to me and to people who loved me. What I want to draw out is narrower and more institutional: this is the first place I learned, from the inside, that a classification system can be accurate about some things and blind to others at the very same moment, and that the blindness is not incidental. It is built into what the category was designed to see.

Reframing the Question: Not Which Label, but Whose Category

My training runs through ethnomethodology, and I want to hold this note to that discipline rather than let it collapse into a referendum on whether "triple-challenged" is a good or bad word. Harvey Sacks's work on membership categorization gives a better question than "is this term acceptable": who uses a category, to categorize whom, on what occasion, as part of what collection of categories, and with what practical and inferential consequences (Sacks, 1972, 1992)?

Labeling theory sensitized sociology to the differential power to apply consequential classifications — Becker's founding claim that "social groups create deviance by making the rules whose infraction constitutes deviance, and by applying those rules to particular people and labeling them as outsiders" (Becker, 1963, p. 9). Membership categorization analysis permits a more fine-grained examination of how such categorizations are actually deployed, by whom, and made inferentially consequential in specific occasions of use (Sacks, 1972; Schegloff, 2007). Sacks is the theoretical engine of this note; Becker's contribution is background sensitization to the stakes of labeling, not a framework I am extending here.

That distinction does real work, because "dual diagnosis" and "triple-challenged" are not just competing synonyms for the same referent. They are different kinds of categorization, generated in different social worlds, doing different practical jobs.

"Dual diagnosis" became institutionalized within a professional apparatus of psychiatry and addiction treatment over the 1990s and 2000s: the term entered the subject index of a leading psychiatric journal in 1989, and by the early 2000s managed-care systems, treatment-authorization panels, and clinical documentation standards had built around it a defined administrative apparatus, including a national consensus process on standards of care for co-occurring disorders in managed-care settings (Drake & Wallach, 2000; Minkoff, 2001; CMHS Managed Care Initiative Panel on Co-occurring Disorders, 1998). I want to be careful to distinguish that institutional career from any claim about where the term originated, which is a separate historical question this note does not settle. Whatever its origin, calling someone "dually diagnosed" today does more than describe two conditions; it renders that person recognizable and actionable as a particular kind of institutional case — a case a given system knows, in advance, roughly how to process.

"Triple-challenged," in my usage, has a different history. I have used it not only as a sociologist and outreach worker describing a population but as someone who identifies autobiographically with the population being described. "I was triple-challenged" and "they are triple-challenged" are not analytically equivalent utterances, even though they share three words. The empirically safest formulation is that it is a self-category produced by a competent member of the social world being described, and subsequently extended to recognizable others. Whether it ever became a shared vernacular category among unhoused people themselves — rather than my own category, extended outward by me — is a separate empirical question this note cannot answer.

Who Gets to Name Whom

Sacks gives a precise way to see how naming organizes accountability. Categories such as "homeless," "addict," "mentally ill," "dual diagnosis," and "noncompliant client" make different predicates and inferences conventionally available. A missed appointment, produced by an ordinary housed patient, is more readily accountable as an unfortunate circumstance; the same missed appointment, produced by someone already categorized as chronically homeless, mentally ill, and substance-dependent, is more readily available to be heard as evidence of "noncompliance." The categorization does not mechanically determine the outcome, but it makes certain accounts more readily intelligible than others — which is itself consequential, since institutional gatekeepers are rarely neutral about which account they reach for first. This connects to what my own work elsewhere calls documentary sorting and documentary sedimentation: a category enters a record, circulates through organizations, and becomes available to organize how the next encounter is read, before the person categorized has said a word.

Against that asymmetry, naming myself is a different social act. Nobody's benefits are denied because I call myself triple-challenged. Nothing about my access to shelter or medication changes based on that sentence. It is testimony, standpoint, self-categorization — not classification imposed from outside. The asymmetry does not fully resolve, though, when I extend the same word to Rafael, Paco, Tina, or the names on the vigil list. They did not choose the term. I want to name the mechanism correctly rather than reach for a borrowed one: this is not reclamation in the sense that crip, queer, or mad-pride politics use that word, since I was not reclaiming a category first imposed on me by outsiders — by my own account I coined or independently adopted the phrase myself. The more accurate description is self-naming, extended. That does not resolve the asymmetry; it just names it correctly. When I extend a self-category outward to others who did not choose it, I am doing something closer to the original act of professional naming than to reclamation, and that is exactly why it deserves more scrutiny, not less, given the "wounded witness" standpoint I have claimed for this work.

What Triple-Challenged Names That Dual Diagnosis Cannot

Imagine two people experiencing psychosis and problematic substance use. One has an apartment, medication stored safely, food in a refrigerator, a bed, a working phone, family or friends nearby, a healthcare provider, transportation, privacy, and a daily routine. The other sleeps outside, repeatedly loses medications, is awakened and displaced without warning, experiences victimization, has no refrigeration or privacy, cannot reliably charge a phone, struggles to keep appointments, and faces discrimination for being visibly homeless. Institutionally, both may be classified identically: dually diagnosed. Sociologically, their situations barely resemble one another.

I do not want "housing as stabilization infrastructure" to do more work than it can bear. Housing is not magical, and it is not sufficient on its own. Some housing is unsafe, unstable, isolating, coercive, or actively incompatible with recovery. What matters is not shelter as a symbol but the specific bundle of practical affordances that stable housing ordinarily makes possible: a place to secure possessions, store medication reliably, sleep on a schedule, maintain hygiene, prepare food, retreat from stimulation, keep a phone charged, and sustain continuity with a provider across appointments. Research on Housing First programs, which place people in permanent housing without first requiring treatment compliance or sobriety, offers indirect support for this narrower claim: Housing First participants achieved earlier and more stable housing without any corresponding worsening of psychiatric symptoms or substance use relative to programs that made housing contingent on treatment (Tsemberis & Eisenberg, 2000). That finding does not show that housing alone stabilizes everyone; it is consistent with the claim that housing's absence changes the manifestation, management, and consequences of the other two conditions, which is the narrower and more defensible claim this note relies on.

This is also where "triple-challenged" does a specific piece of categorization work that "dual diagnosis" structurally cannot: it crosses collections that institutions keep separate by design. The housing system encounters a homeless person. Psychiatry encounters a psychiatric patient. The substance-use system encounters a client with a use disorder. Each system's categories are built to be legible within that system, not across it. "Triple-challenged" gathers together what institutional categorization practices routinely pull apart — which may be read either as an achievement, naming a real convergence that fragmented systems refuse to see as one life, or as a category error, falsely uniting phenomena that are genuinely heterogeneous. I do not think either interpretation should be settled in advance.

Additive Grammar, Recursive Phenomenon

The additive model: mental illness + addiction + homelessness = the triple-challenged person. This is the formulation I have elsewhere named and rejected. Its flaw is architectural, not merely rhetorical: it treats three heterogeneous phenomena — an inner psychiatric state, a practice or relationship with a substance, and a material condition — as three parallel "challenges" located in the same place, the person. Housing is not a psychological achievement. Folding it into a personal profile alongside mood and substance use quietly moves causality inside the individual and away from unaffordable rents, wages that have not kept pace with housing costs, trauma, the criminalization of survival behavior, fragmented treatment systems, and the plain scarcity of sustained care.

Elsewhere in my own prior work, I described the combined effect of these three conditions on institutional processing as "not additive... but exponential." I want to revise that word now rather than repeat it uncritically: "exponential" implies a specific mathematical form I have not demonstrated and do not think I can. What I can defend is narrower and still substantive — the relationship is recursive and mutually amplifying rather than simply additive. Homelessness amplifies psychological distress and makes treatment harder to sustain; psychological distress impedes the sustained effort housing applications require; substances may function as self-medication for the first two conditions while independently increasing vulnerability to all three; street conditions intensify substance use; and each of the three exposes a person to institutional sanctions that further destabilize the other two. I keep the earlier "exponential" language here only as a quotation of my own prior formulation, not as my current claim.

Both things can be true at once, and I think the honest move is to say so rather than resolve the tension by fiat: the term's grammar is additive — "triple" reads as three discrete, equivalent things — while the phenomenon it names is recursive and mutually amplifying. That is a genuine defect in the word's architecture, not a misreading by critics.

Remaining Costs of the Term

The category-error and individualization objections are developed above and I will not repeat them here. Three further costs remain, and I do not think any of them is fully answered by the analysis so far. "Challenged" can run the opposite direction from euphemism-as-flattery: applied to someone floridly psychotic, repeatedly overdosing, profoundly traumatized, and sleeping in danger, it can sound administratively mild — almost a compliance term — for a condition that should be named plainly. At the same time, each of the three component terms compresses real variation: "mental-health challenge" spans manageable anxiety and disabling psychosis; "substance-use challenge" collapses distinctions among use, dependence, self-medication, and life-colonizing dependence; "homelessness" spans temporary instability and years of unsheltered street survival. A single compound term obscures all of that range at once. Finally, the asymmetry from the previous section has a practical edge: a designation I choose for myself becomes ethically different the moment I apply it to someone else who never chose it and may not want it, and centering this population narratively risks reinforcing a public perception that homelessness is primarily individual pathology — letting readers maintain distance, "that's not me," from a structural argument meant to implicate ordinary institutional operation rather than extreme cases alone.

The Retirement, and Where Things Actually Stand

My earlier decision to retire the term was genuine, and so were the objections that produced it. I have not subsequently concluded that those objections were mistaken. Rather, returning to the question has made visible something the critique itself obscured: "triple-challenged" has never functioned for me solely as an analytic classification imposed upon others. It is also a category through which I have named my own experience and recognized people whose lives resembled mine. I therefore retain the term provisionally and reflexively — not as a diagnosis, not as a designation I presume everyone would accept, and not as an adequate causal model of the phenomena it names. I retain it as a situated category whose history, uses, limitations, and consequences are themselves sociologically interesting.

Alternatives Considered, and Why None Replaces It Cleanly

Clinical and administrative synonyms — tri-morbidity, triple diagnosis, high acuity, complex needs — function as institutional euphemisms doing the same sorting work as dual diagnosis; none is an improvement so much as a relabeling of the same apparatus. "Tri-morbidity" in particular commits almost exactly the category error at issue, by medicalizing homelessness outright.

Structural and academic alternatives — intersecting vulnerabilities, compound disadvantage, compound suffering, complex street lives, the homelessness–mental distress–substance use nexus, people experiencing homelessness with co-occurring mental-health and substance-use disorders — each solves something and loses something. Some are analytically precise but nothing anyone would say about themselves. Some avoid deficit language by drifting into euphemism. Some name the structural relationship while losing the person.

A third option is no replacement noun at all: rather than a better label, the alternative may be a set of situated questions asked of each person — what has happened to them, what a substance is doing in their life right now, what housing, income, relationships, and care are or are not available to them, how institutions have classified and responded to them, and what they themselves want to preserve or change. This trades nominal classification for situated inquiry, a shift in method rather than a substitution of words. It may be that the analytically best term and the meaningful self-identification are not required to be the same term; that is consistent with the Sacksian approach taken here, in which a category's adequacy depends on the occasion of its use rather than on finding one word that performs every job at once.

Why This Population Matters Regardless of What It Is Called

Whatever name survives this note, the underlying fact does not depend on it. National point-in-time count data collected under HUD's Continuum of Care program found that in 2023, roughly one in five people experiencing homelessness had a serious mental illness and about one in six a chronic substance use disorder (U.S. Interagency Council on Homelessness, 2024) — figures that most researchers treat as undercounts, since point-in-time counts are known to miss unsheltered people and those cycling through institutions on count night. This is not merely a behavioral-health problem. It is a social fact requiring explanation. These lives sit precisely where several major American institutions intersect and routinely fail one another — housing markets, behavioral healthcare, addiction treatment, emergency medicine, criminal justice, disability systems, and homelessness services.

The sharper claim is not simply that these systems fail to coordinate, but that each one operates on a reciprocal presumption about what another system is supposed to provide. For most of the past several decades, the dominant "treatment first" or "housing readiness" model required demonstrated psychiatric stability, treatment compliance, and sobriety as preconditions for permanent housing (Tsemberis & Eisenberg, 2000). Clinical and ethnographic accounts of the resulting "institutional circuit" — the cycling of homeless mentally ill adults among shelters, hospitals, and jails — documented how each system in that arrangement presupposed capacities that, in practice, only a different system could reliably provide: outpatient psychiatry presupposes reliable communication, transportation, medication storage, and appointment-keeping, all of which are themselves products of stable housing (Hopper, Jost, Hay, Welber, & Haugland, 1997). The triple-challenged person becomes, in the vocabulary of my larger project, an institutional limit case precisely because those reciprocal presumptions collapse simultaneously: the one system that could stabilize behavior is withheld pending behavioral stability; the one system that could stabilize housing is withheld pending housing stability. This is the direct bridge to Abandonment in Real Time's account of the transformation chain — one life, integrating exactly what several institutions have fragmented, at cost to the person doing the integrating.

Returning to Whose Category

I continue to call myself triple-challenged not because three deficits define me, but because three formidable struggles once converged in my life. I use the term for others more cautiously, knowing that self-categorization and categorizing another are different social acts. "Triple-challenged" is therefore neither a diagnosis nor a proposal for a new administrative population. It is a situated category with a history, a constituency that cannot be presumed, and practical consequences that depend on who uses it, of whom, and for what purpose. That is finally why the question is not simply whether "triple-challenged" is the right category. The sociological question is whose category it is, what work it does, and what becomes visible — or disappears — when it is used.

References

Becker, H. S. (1963). Outsiders: Studies in the sociology of deviance. New York: Free Press.

CMHS Managed Care Initiative Panel on Co-occurring Disorders. (1998). Co-occurring psychiatric and substance disorders in managed care systems: Standards of care, practice guidelines, workforce competencies, and training curricula. Rockville, MD: Center for Mental Health Policy and Services Research.

Drake, R. E., & Wallach, M. A. (2000). Dual diagnosis: 15 years of progress. Psychiatric Services, 51(9), 1126–1129.

Hopper, K., Jost, J., Hay, T., Welber, S., & Haugland, G. (1997). Homelessness, mental illness and the institutional circuit. Psychiatric Services, 48(5), 659–665.

Minkoff, K. (2001). Best practices: Developing standards of care for individuals with co-occurring psychiatric and substance use disorders. Psychiatric Services, 52(5), 597–599.

Sacks, H. (1972). On the analyzability of stories by children. In J. J. Gumperz & D. Hymes (Eds.), Directions in sociolinguistics: The ethnography of communication (pp. 325–345). New York: Holt, Rinehart & Winston.

Sacks, H. (1992). Lectures on conversation (Vols. I & II) (G. Jefferson, Ed.; E. A. Schegloff, Intro.). Oxford: Blackwell.

Schegloff, E. A. (2007). A tutorial on membership categorization. Journal of Pragmatics, 39(3), 462–482.

Tsemberis, S., & Eisenberg, R. F. (2000). Pathways to Housing: Supported housing for street-dwelling homeless individuals with psychiatric disabilities. Psychiatric Services, 51(4), 487–493.

U.S. Interagency Council on Homelessness. (2024). Federal resources for addressing the behavioral health needs of people experiencing or at risk of homelessness. Washington, DC: Author.