Category: Education

Categories
Education Fiction

Timing.

It was 4:38pm and the consult pager beeped. The attending psychiatrist sighed with displeasure. That pager always seemed to go off during those last few minutes at work.

The resident returned from the phone call and reported, “It sounds like there’s a young woman who just got through surgery. She’s in the PACU (post anesthesia care unit) and won’t stop crying, no matter how much pain medication she gets. Surgery is asking for help.”

The attending looked at his watch and grunted. “We don’t have to do a full consult now. We can patch things over for the night and finish up tomorrow.”

His legs were long and the tassels on his loafers swished with each step he took. To keep up with him, the resident was almost running.

When they arrived in the PACU, the nurses looked up. As they put their heads back down, they wordlessly pointed to the other side of the room.

Laying in the gurney was a young woman who was sobbing. Her breaths were irregular, choked. Tears flooded her flushed cheeks and plastered locks of hair to her face. The hospital gown was too big for her and she was somehow slumped in a reclining position.

The attending approached and wrapped his hands around the railing of the patient’s gurney.

“My name is Dr. Tom.”

A new wave of tears washed over the patient. Shoulders quivering, she put her hands over her face and nodded at him.

“We’re from the psychiatry service.” He tilted his head to gesture at the resident standing behind him, who nodded and offered a meek smile. His speech was cool, clipped. “The surgeons say that you’ve been upset since the surgery. What happened?”

“I… don’t… know,” she sobbed through her fingers, her voice thin and strained.

“Are you feeling sad?”

Uncovering her face, she nodded. She raised a limp hand and wiped her eyes.

“Are you feeling scared?”

“I’m… so alone,” she blurted between gasps. “No one is here. No one is taking care of me.”

“Uh huh.”

The resident glanced at them. The patient looked distressed and the attending looked bored. The resident shifted uncomfortably.

“Miss, can I ask you a question?” Dr. Tom turned and cast a knowing glance at the resident: Pay attention. Here comes a clinical pearl.

The patient nodded, her red eyes still welling with tears.

“Were you sexually abused when you were a kid?”

The resident felt her breath catch in her throat.

The patient’s chin began to quiver. She tore her eyes away from the attending and buried her face in her hands. After choking on a few gasps, she mumbled, “Yeah.”

“Okay,” Dr. Tom said, leaning back and releasing the gurney rails. “Some people feel alone and scared after surgery. We’ll ask the nurses to give you more pain medication, that’ll help you feel more comfortable. We can talk more tomorrow morning, maybe about ways you can feel less lonely while you’re here.”

The patient nodded, sniffing.

“So we’ll see you tomorrow. Good-bye!” He flashed a toothy smile, waved, and walked away.

The patient looked at the resident, who waved weakly before turning to catch up with the attending.

Once out of PACU, the resident blurted, “Why did you ask her about sexual abuse?”

“Borderline personality disorder. They often have a history of sexual abuse. Her presentation was consistent with that diagnosis.”

She opened her mouth to say, No, I meant why did you ask her about it at that moment? Couldn’t it wait?

Instead, she heard herself say, “Oh. Thanks.”

“No problem,” he said, flashing that toothy smile at her. “Now you know what to ask when you see a similar patient in the future. Have a good evening!”

She watched him walk away and wondered if she had done the right thing.

Categories
Education Homelessness NYC

How Long Do People Stay Here?

Let’s visit a homeless shelter in New York City.

There’s no sign on the building. On the sidewalk outside of the unmarked entrance are several men. Three of them are chatting with each other. Two others are leaning against the wall, taking drags from their cigarettes. After you pass, one of them coughs up a wad of phlegm and spits it out. A man sitting on the sidewalk asks, “Spare some change?” He shakes a tattered coffee cup at you. The few coins inside jangle.

You try to pull the door open. It’s locked. Through the glass you see a few people looking out at you. They’re not smiling. Finding the doorbell, you press the white button. A few seconds pass. A harsh, steady buzz suddenly fills the air, informing you that you may now enter.

“Sign in!” a man barks at you. Behind the splintered desk is a man in a security uniform. He’s pointing at a log book, the page nearly filled with names in blue ink.

As you write in your information, he asks, “Who are you? Where you from?”

“Empty your pockets.”

“Open your bag.”

Satisfied with your answers and confident that you don’t have weapons, drugs, or alcohol, he steps out from behind the desk with a metal detector wand. After he waves it over your body, he says, “Go. You’re fine.”

Before you see the thick, plastic chairs in the main room, you smell the odor of fetid sweat. Seated in the chairs are men wearing unwashed jeans, oversized shirts, baggy jackets, and generic baseball caps. Some of them are reading newspapers and books. A few older women are sleeping upright, their chins nearly resting on their chests. One of them is wearing sandals; her toenails are discolored and misshapen from fungus. Her ankles look like eggplants. A young man seated in a wheelchair tries to drink his coffee, but his tremulous hand cannot keep the cup steady. Next to him is a man wearing a porkpie hat, red lipstick, two winter coats, board shorts over torn tuxedo pants, and yellow sandals. Three women are shouting at each other; one of them reaches for the neck of another and screams, “I’M GONNA KILL YOU, YOU—”

“How long do people stay here?” you ask, realizing that the room is filled with people. You can’t imagine living like this; you’d get out of here as soon as you could.

They feel the exact same way.

But you ask an excellent question. What is the average length of stay in a homeless shelter?

Some caveats: Data on homelessness is almost always incomplete and inaccurate:

  1. Researchers can only collect data that is available. People who stay in homeless shelters are available. People who live in cars, abandoned lots, and in transit stations—away from researchers—are generally unavailable.
  2. Researchers often must rely on the information homeless individuals share (“self report”). For a variety of reasons, people who are homeless may not share much about themselves… if they consent to interviews at all.

That being said, available evidence suggests that people stay in homeless shelters anywhere from two [1. “The average length of stay in emergency shelter was 69 days for single men, 51 days for single women, and 70 days for families.”] to seven months. [2. “In a survey of 24 cities, people remain homeless an average of seven months…”] (I read a paper within the last year that I now cannot find—of course—that demonstrated that the majority of people who experience homelessness are homeless for less than six months. Furthermore, of those people, most of them are homeless for only one day!)

This suggests that the majority of people in shelters do not experience chronic homelessness. Emergency shelters, then, are arguably used just for that: emergencies. Those who enter shelters obtain the help and resources (either within or outside of the shelter) to get them back on their feet. They exit the shelter system in less than a year—sometimes within a few months—and never use the system again.

However, there are individuals in shelters who meet the definition of “chronically homeless”. Some researchers have “identified that approximately 10 percent of users account[ed] for 50 percent of the annual nights of shelter provided”. [3. See page 1-10 of this document for the statistic that 10% of shelter users account for 50% of annual nights of shelter provided.] These numbers should sound familiar to those of you who follow health care policy discussions, where “5% of patients use 50% of all health care spending dollars”. [4. More about “A Small Proportion of the Total Population Accounts for Half of All U.S. Medical Spending” here.]

So what’s going on with these individuals who experience chronic homelessness? Are there risk factors for chronic homelessness? If so, what do you think they are?

Categories
Education Homelessness

What Does “Homeless” Mean?

So you’ve thought about the definition of the word “homeless”. Question: Which of the following people would you consider “homeless”?

Ms. Alfa was living in a one-bedroom apartment until the entire building burned down in a fire. She’s been “couch surfing”—spending a few nights at a friend’s apartment, then a few nights at her sister’s house, etc.—for the past two weeks.

Mr. Bravo works in the pizzeria around the corner. He’s the guy tossing the pizza dough in the window. For the past year, he’s had an agreement with his boss: He closes the restaurant every night at midnight and cleans up the shop. He can then sleep on some cardboard in the pantry until seven o’ clock in the morning.

Ms. Charlie is in jail. She was renting a room, but still has another six months left in her sentence. She has been evicted from the room because of unpaid rent. She lost her job due to her incarceration and has no other sources of income.

Mr. Delta lost his job as a construction worker after his left leg was amputated. A man pushed him onto the subway tracks when a train was approaching. While he was in a physical rehabilitation center, his landlord evicted him on false allegations. Mr. Delta was discharged from the rehab center to a men’s shelter, where he now shares an efficiency apartment with a roommate.

So? Who’s homeless?

The United Nations has offered a definition of homelessness [1. I can only find the United Nations definition of homelessness on Wikipedia]. Everyone described above would meet that definition.

The United States Code, however, has its own definition of homelessness. Here it is:

For purposes of this chapter, the term “homeless” or “homeless individual or homeless person” includes—

(1) an individual who lacks a fixed, regular, and adequate nighttime residence; and

(2) an individual who has a primary nighttime residence that is —

A. a supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill);

B. an institution that provides a temporary residence for individuals intended to be institutionalized; or

C. a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.

Ms. Alfa would NOT be considered homeless. Though she is “couch surfing”, which implies no fixed or regular housing, she is not spending her nights in a shelter, an institution, or a place “not designed for, or ordinarily used as, a regular sleeping accommodation for human beings”.

Mr. Bravo would likely be considered homeless. The pizzeria is “fixed” and “regular”, though not necessarily “adequate”. The pizzeria meets criteria 2C. Individuals who live in cars, subway stations, and abandoned buildings would also be considered homeless for the same reasons.

Ms. Charlie would NOT be considered homeless, though this is not evident from the definition provided above (see 2B). In practice, it doesn’t matter if someone loses her housing while incarcerated: If she had housing prior to jail, she is not considered homeless, even though she has no place to go upon release. The same applies to hospitalizations. [2. This is often a significant problem. Those who may need housing the most are often deemed ineligible.]

Mr. Delta would be considered homeless (see 2A).

Next: Who would you consider “chronically” homeless?

Does someone have to homeless for at least six months? one year? two years?

Would he have to be homeless for 365 consecutive days? What if he crashed at a friend’s house one week out of every month? What if he rented a hotel room when he had the money to do so?

The federal government has a definition for “chronic homelessness”, too: [3. Chronic homelessness is defined on page 3 of this document. I curiously can’t find it in the United States Code directly.]

… either (1) an unaccompanied homeless individual with a disabling condition who has been continuously homeless for a year or more, OR (2) an unaccompanied individual with a disabling condition who has had at least four episodes of homelessness in the past three years.

Compare this definition to that for “homeless” only. What’s different?

The definition for “homeless” says nothing about duration, nor does it say anything descriptive about the individual. For the definition of “chronic homelessness”, the individual must have been homeless for certain periods of time. Additionally, the person must have a “disabling condition”. [4. I’m not sure what to make of the qualifier “unaccompanied homeless individual”. Does this mean that children with a parent are not considered “chronically homeless”? That doesn’t seem right.]

The government has a definition for “disabling condition”, too: [5. “Disabling condition” is defined on page 4 of this document. I also can’t this in the United States Code.]

… a diagnosable substance abuse disorder, a serious mental illness, developmental disability, or chronic physical illness or disability, including the co-occurrence of two or more of these conditions…. [ In addition,] … a disabling condition limits an individual’s ability to work or perform one or more activities of daily living.

And that is how medicine, including psychiatry, has a role in the care of the homeless.

If you’re thinking that the definition of “chronic homelessness” suggests the medicalization of social issues, you’re not alone. If you’re thinking that medical and social issues are obviously intertwined, you’re also not alone. More on this to follow.

Categories
Education Homelessness NYC

Do All New Yorkers Have a Home?

Before I write about “homeless psychiatry”, let’s talk about homelessness.

In New York City, most people are familiar with the sight of people who are clearly homeless. These men and women, sometimes pushing carts and often saddled with several overflowing bags, are in city parks, on subway cars, and under bridges. People grow so accustomed to the homeless that, after a while, they don’t see them anymore, even if they’re looking directly at them. (Once you are actively looking for them, however, you will see them everywhere—and where they sleep, even if they aren’t there.)

Would you believe that New York City has one of the lowest ratios of street homeless individuals in the country? (Please note that there are differences between people who are homeless on the street and people who are homeless in shelters. More about this below.) In New York City, there is one street homeless person for every 2,688 people in the general population. In Los Angeles, there is one street homeless person for every 154 people. [1. See the last page of the document that compares street homeless populations of different US cities. Briefly, this data comes from volunteers who survey the city on one single night, usually during the coldest month of the year.]

What could explain this? Maybe it’s because of the cold, snowy winters and the sweltering summers. Perhaps people who are homeless leave the city and move to places with temperate climes. Those who have worked in hospitals too long might argue that many of the homeless aren’t on the streets; they’re in the hospitals. Those who work in the correctional system may make the same argument, except they replace the word “hospitals” with “jails”. Or maybe they’re hiding somewhere to avoid encounters with the police.

While those reasons may hold true for some people, one major reason that explains the low ratio of street homeless people in New York is the class action lawsuit Callahan v. Carey. The result of this lawsuit decreed that the City and State of New York must

provide shelter and board to all homeless men [and, later on, women] who met the need standard for welfare or who were homeless “by reason of physical, mental, or social dysfunction.” Thus the decree established a right to shelter for all homeless men in New York City, and also detailed the minimum standards which the City and State must maintain in shelters, including basic health and safety standards. [2. Excellent summary of Callahan v. Carey.]

As far as I know, New York is the only state where people have a legal right to shelter.

Even though New York City has a low ratio of unsheltered homeless individuals, there are many people who are homeless who stay in shelters. The Department of Homeless Services in New York (which also shares the acronym “DHS”) keeps a count of homeless individuals throughout the city.

Take a guess: How many people stay in a New York City shelter on an average night?

Those of you who have witnessed the New York City Marathon can attest to the endless waves of people who are running (plodding, whatever) in the streets. Tens of thousands of people make their way towards the finish line. About 45,000 people finished the marathon in 2010.

New York City’s Department of Homeless Services publishes the shelter census every day. The number has recently been around 37,000 people. While there is a difference between the shelter census number and the marathon finisher number, you now have a sense of the size of the shelter population.

Take another guess: How many of those 37,000 people are children?

About 16,000. [3. Statistics about the population of homeless people and children in New York.]

That’s right: In New York City shelters, there are more homeless children than homeless single adults.

These numbers tell us only about people who are willing and able to go through the process of registering for and staying in shelter beds. There are people who are homeless who either cannot or choose not to stay in shelters. [4. Here is a literary example.] As far as I know, there is no literature that describes the differences between these two populations, though I suspect that the differences are significant.

Furthermore, there are major differences between people who are homeless for a shorter period of time versus those who are “chronically” street homeless.

But before we get into those distinctions, let’s think about the definition of “homeless”. Many scholars, politicians, and advocates have tried to provide an accurate description of this word. How would you define it?

Categories
Education

Termination (III).

Her phone began to ring as she was putting socks into her luggage. It was him.

“Hey,” she greeted.

“So I can’t take you to the airport. Something came up.” He sounded distracted.

“Oh.” She paused, waiting for him to elaborate. He said nothing. “Can we still meet for lunch?”

“No, something came up last minute. I actually gotta go soon—”

“But I was hoping that we could spend some time together before I move. You know, to say good-bye.”

“Yeah, so was I, but this thing came up and I just can’t. I’m sorry.”

She frowned.

“Look, I gotta go,” he said. “I’m sorry about this, but I’ll call you in a few days to make sure everything went okay.”

“I don’t know when we’ll see each other again. Is there—”

“I really gotta go. I’ll call you. Have a safe flight!”

She heard a click, then silence.

Malan (p. 220) remarks:

[One] pattern is that when the therapist starts talking about termination the patient announces that he doesn’t want to come any more. [A]lthough the patient suffers by losing even more therapeutic time, he gains by retaining control of the situation and turning the tables on his therapist by leaving rather than being left.

Sometimes patients don’t attend their final appointments with their therapists (or good-bye parties, graduations, etc.) so they can avoid feeling emotions—”positive” or “negative”—associated with termination. If you don’t have to talk about it, that means you don’t have to think or feel anything about it. In this way, avoidance as a coping strategy works.

If you never say hello, you will never have to say good-bye. That also means, though, that your experience of the world—and of yourself—is limited. Some people want that. Many people don’t.

(Read more about termination in part one and part two.)