A sample agenda as the consulting psychiatrist with a homeless outreach team:
8:17am. Arrive at the office, which is in a tall building that is a short walk from the New York Stock Exchange. Speak with the case managers and social workers about who should be seen that day.
8:55am. Walk with a case manager to the ferry terminal meet Paul[1. All patients described here are composites of people I have seen across time.], who is a young man the outreach team has seen over the past two weeks, particularly in the early morning. Paul has said that he lives with his father in Washington Heights. When asked why people see him at the ferry terminal at night, he only repeats that he sleeps in his father’s apartment at night and walks the 10 miles to and from the ferry terminal every day. He doesn’t say much to people, but he’s often mumbling to himself. The security guards have shooed him out. He returns everyday.
He’s sitting in a chair with a ripped jacket draped over his head. Dirty sweatpants that are three sizes too big hang off of his slender frame. When he hears “good morning, outreach team” for the third time, he slowly pulls the jacket off of his head. His eyes are closed. When he hears “are you okay?” for the second time, he opens only one eye. With some prodding, he says his name, but says little else.
“I gotta go to work,” he says as he gets up. The sweatpants begin to slide down his hips. He’s not wearing any underwear. He starts to walk away and the legs of the sweatpants begin to bunch around his ankles.
“If you want, we can get you a pair of pants that will fit you better—”
He starts to walk faster and does not listen to entreaties to stop. With his left hand he grasps the waistband of his pants and walks down the escalators. He blends into the crowd of people exiting the terminal and is soon on the road outside, walking north.
“That’s Paul,” the case manager says.
“We’ll try again tomorrow.” Provide teaching on different strategies to build rapport—maybe present him with a pair of pants? a package of underwear?
9:20am. Say good-bye to the case manager and hop on a subway and head uptown, but don’t exit the station. On a bench near the rear of the station is Eleanor. She’s been homeless for over twenty years. She’s wearing two jackets and her fingernails are painted pink. No one has ever seen her nails unpainted. They always look manicured.
She’s darning socks with her wrinkled hands. Nearby is her large rolling suitcase, which is open today; inside are more jackets, several pairs of shoes, and two large bags of potato chips.
“Hello,” she says quietly. She smiles. She reports that she is fine, but her back hurts this morning. She wasn’t able to lie down last night to sleep. The security guards frequently asked her to move.
“You could move into a small apartment where security guards wouldn’t bother you. It would be your own space.”
“Oh, but I can’t,” Eleanor says. “They will exterminate me if I do that.”
She’s said this consistently over the past seven months.
“The alien transmissions—they use the satellites—tell me that I’m not allowed to move inside. They’ll exterminate me if I do. They’ll use electrocution. I don’t want to be exterminated. I can’t.”
With much coaxing, she’s actually been able to visit a housing project to see a studio apartment, but she refused to actually step into the room.
“I’ll get exterminated.”
She also declines to take any medication.
“The only medicines that work are potato chips and chocolate. Dark chocolate works better than milk chocolate. I feel better when I eat chips and chocolate.”
It’s hard to argue with that. She declines housing again today, but she’s open to another visit later on in the week.
10:00am. Get back on the subway and get off at the stop two stations away. Climb the stairs out of the station. Barry is sitting cross-legged in front of the bodega. He’s rocking back and forth while smoking a cigarette. Barry says he’s been homeless for the past eight years and the bodega owner says that Barry has been sitting out there for the past five years.
“I’m sorry,” Barry greets. A stranger leans over and leaves a deli sandwich and coffee for him. Barry mumbles, “Thanks.”
The dirt on his arms and hands indicate that he hasn’t showered in several weeks, maybe a month. Dirt is packed underneath his fingernails and bits of food are stuck in his beard. His fingertips are yellow and knobby with callouses.
“I gotta get back to work, I gotta get back to work,” he says, pointing at the building across the street. “I think my boss would give me a job again, I did good work while I was there, I did good, I did good.”
Barry also declines housing again today. “I gotta get a job first before I get an apartment. A man’s gotta work first, he’s gotta work, I gotta get back to work.”
The office receives his monthly cheques for disability (schizophrenia), but he won’t withdraw any money. His bank account has tens of thousands of dollars in it. He could afford to rent a small room, but he won’t do it. He can’t say why.
“It’s starting to get cold. If you don’t want to move inside, can I at least bring you a jacket or two?”
Barry stubs out the finished cigarette. He stops rocking.
“Yeah, sure,” he finally says.
11:00am. Team meeting. Discuss progress on different clients the team is following. Two people moved into transitional housing in the past week! One moved into permanent housing. People are excited about the individual who moved into permanent housing because he was homeless for over ten years. He often shouted at and hit himself for sins he said he committed. Despite that, everyone liked him, including the police, because he also had a sharp sense of humor. He also fed the pigeons every day.
He refused to move inside for over a year. After multiple visits to the housing project, he finally said he would give it a try. It’s been three days and he hasn’t left. Sounds like he was adjusting fairly well to his new digs, but he still sleeps on the floor.
12:00pm. Lunch. Chart the encounters in the morning.
12:45pm. A case manager brings a man to the office who is willing to sit for a psychiatric evaluation. A plastic bag hangs from the man’s hand. Inside is a brown paper bag that holds two 24-ounce cans of beer. One of them is open. He looks down at the bag.
“I won’t drink this now. Please don’t throw them away.”
He’s been homeless for four years. He was sleeping on the floor of the pizza parlor where he worked as a sweeper, but the owner was closing the business because of financial problems. He now sleeps on trains, in subway stations, sometimes in parks. He tries to avoid the shelters because people have stolen things from him.
“I know I have an alcohol problem,” he says, his eyes sad. “It wasn’t always this bad. I don’t know how to stop. Sometimes I think I will never stop, even though I hate waking up in the hospital. Life is too hard. Beer helps me feel better. ”
1:45pm. Charting that encounter. Diagnosis determines what housing he is eligible for.[2. “Diagnosis determines what housing he is eligible for.” This is an example of psychiatrist as an agent of social control.] It’s not clear if he has a “severe and persistent mental illness”. Suggest that he return in a week; the meeting can happen outside if that’s easier. No recommendations for medications right now, but harm reduction in his alcohol use would probably be helpful. He demonstrated insight, but that may not result in behavior change.
1:55pm. Case manager asks for help with a person who lives in a park. Hop into the team vehicle and drive north.
2:20pm. Arrive at the park. The client was there earlier in the day and said that he would be there, but a walk through the park shows that the client isn’t.
Three people by the picnic tables wave hello. The outreach team sees them regularly, though they are not eligible for this program. They have been drinking, but they are not grossly inebriated. They laugh as they tease us for following them around; everyone is now enveloped in the strong fragrance of fruity, sugary alcohol.
They each hold a bottle of beer that sits inside a wrinkled brown paper bag. They offer some. They aren’t offended when their offer is declined.
2:30pm. Walk around the park one more time to find the original client. He’s still not there. Children play with a ball on the lawn, multiple games of chess are in play, students read thin books on park benches, couples hold hands as they walk along the park paths, elderly women sit and watch people walk by. The three people who are drinking alcohol laugh loudly.
2:55pm. Arrive back at the office. A client is sitting in a chair by the door. He says nothing, but he looks upset.
A case manager requests consultation.
“This guy never agrees to come in,” she whispers. “Maybe you could talk with him? He’s been homeless for a long time, but finally agreed to move into an apartment about eight months ago. He was doing fine, even saw the psychiatrist there once or twice… but apparently he’s been sleeping outside for the past two days and won’t say why.”
There are introductions. The man doesn’t want to get up from his seat. He frequently looks at the door during the stilted conversation.
“How are you, Charlie?”
“Fine.”
He learns what the case manger shared. He says nothing.
“How long have you lived there?”
“A few months.”
“What’s it like?
“Noisy.”
“Anything you like about it?”
“It’s warm.”
He suddenly starts talking about the freedom of living outdoors, except the cops harass him sometimes. He also doesn’t like the kids who try to set him on fire. The zombies send them to do that. He’s tired of the zombies.
“Who are the zombies?”
“I don’t know! Stop asking me questions!”
He abruptly gets up. Everyone pauses.
Charlie wipes his mouth on his sleeve. He drops back down into his seat.
“The zombies want me to be homeless. Every day, same thing: ‘You’re a homeless motherf-cker’. Damn!”
He talks more about the zombies and his apartment.
“You wanna try going back this afternoon? We can take you there. It’s starting to get cold out. You mentioned that your apartment is warm.”
Charlie chews on his lip and snarls.
“Let’s get into the car so I can drive you back,” the case manager gently says. He says nothing, but he gets up and walks out of the office. Everyone looks at him.
“You gonna drive me back there now or what?” Charlie mumbles.
3:45pm. Go visit a local church to try again to speak to a young man. No one is certain of his name. He believes the church is his home: The pews are his beds, the altar is his kitchen. He has washed his clothes in the font of holy water. He occasionally yells “in tongues” at parishioners. When security guards have consequently escorted him out of the church, he has tried to “cast the devils out” of them. He notably avoids the church during formal services.
Inside the church, tourists and visitors speak in hushed voices as they walk through the aisles. The security guards nod hello.
The young man is seated quietly in a pew in the chapel. His eyes are closed. He doesn’t respond to whispered entreaties to go outside and talk. He keeps his eyes closed, his hands clasped, and he breathes quietly. Another security guard watches him.
4:05pm. Back at the office. Charting.
5:05pm. Depart the office and get swept into the current of people walking towards the subway stations. Automatically look for people who are homeless along the way. It’s too crowded right now; the homeless can’t find any places in there that offer peace.
Step onto a train and notice a sleeping man holding a tattered backpack to his chest. His clothes are soiled, including his three oversized coats and flimsy cap. The soles of his shoes are ripping off, showing the dingy yellow socks inside.
A lot of people get up so they don’t have to stand or sit near him. Most people don’t look at him.
I do.
Maria Yang, MD 