Category: Homelessness

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Education Homelessness Medicine Nonfiction NYC Observations PPOH

Daily Schedule: Homeless Outreach Team.

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.

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Homelessness NYC Observations

Memorial.

Two weeks had passed before I learned what happened.

I hadn’t seen him in several months. At our last meeting, the trees were full of red and orange leaves. He, as usual, was not interested in talking to me. He was sitting in front of a closed shop.

“Hi. How are you?”

“Fine.”

People in the neighborhood took care of him. Surrounding him were several plastic bags holding neatly stacked styrofoam containers filled with soup. Another bag held several pastries, most of them still wrapped in clear cellophane. Another bag contained many empty, crushed water bottles.

“Anything new happening?”

“No.”

He was old enough to be my father, though he looked like he could be a grandfather. Time had taken away some of his teeth. The joints of his fingers were knobby. Crescents of dirt were caked underneath his nails. He was wearing a different coat.

“You got a new coat.”

“Yes.”

He previously wore a blue windbreaker; now he was wearing a puffy black jacket that was three sizes too big for him. His thin neck poked out above the collar. The jacket was unzipped and showed the soiled white tee shirt he wore underneath.

“Any more thoughts about going inside for the winter?”

“Not now.”

People were starting to gather around us. In that particular neighborhood, passersby routinely stopped and gawked whenever I spoke with people who appeared obviously homeless. They were staring at us, their mouths hanging open, their faces perplexed.

“Can I help you?” I barked at them, doing nothing to mask the irritation in my voice.

In response, they closed their mouths, turned away, and walked on. (Related: One of the fastest ways to get people in New York to stop looking at you is to say, “Hello!”)

“Where are you sleeping now?”

“In the park.”

Sometimes he slept in a box. He usually slept on a flattened box, and it often wasn’t in the park. People had seen him underneath nearby construction scaffolding. Others saw him in the subway station, though he didn’t seem to use the subways at all.

He said that he had been outside for “a while”. Records from the shelter and from concerned citizens in the neighborhood suggested that he had been outside for at least 20 years.

“I know you’ve heard this before, but just humor me: You don’t have to stay outside. You can stay in a small studio apartment where they serve two meals a day, you can store your belongings there—”

“I’m okay.”

I felt for him. I wouldn’t want to talk to me if I were him.

When homeless people disappear from their usual locations, I wonder: Have they moved to a different neighborhood? Were they arrested and now in jail? Did they find a place to live? Are they in a hospital?

I often never find out.

This man had died. He contracted pneumonia and was in an intensive care unit for about a week. Was there a code? Did the physicians withdraw care? If so, who made that decision? Was anyone with him when he died?

There was no funeral. There was no memorial. Did anyone from the neighborhood notice that he was gone? Did any of those people who gawked at us notice his absence? Did people assume that he ultimately agreed to go into housing, that he finally changed his mind?

Did anyone think that he had died? Did anyone miss him?

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Education Homelessness Informal-curriculum Lessons Medicine NYC Observations Policy PPOH

Supervision and Support.

To conclude a description of my previous job at PPOH in New York, let me tell you about Friday afternoons.

Every Friday afternoon, the staff psychiatrists met as a group for three hours.

Those three hours were important and valuable. During that time, a variety of activities occurred:

Case presentations. Different psychiatrists presented cases to solicit ideas and help. Hearing the thoughts of others provided fresh perspectives and helped us “think outside of the box”. Each psychiatrist had his specific strengths and this forum allowed us to access his expertise.

Example: Someone once presented a case about a woman who was refusing to accept treatment for a major medical problem. The psychiatrist had assessed her decisional capacity and it appeared intact. This meant that we—other doctors, her psychiatrist, other non-medical staff members—had to respect her wishes… and also watch her become more ill and eventually die. The psychiatrist who presented this case wanted to (1) ensure that his assessment of her decisional capacity was thorough, (2) learn how to manage the (often angry and frustrated) reactions of the other physicians and non-medical staff, (3) get ideas about how to coach the other physicians involved in the patient’s care when they wanted to do something and she refused, and (4) vent and get support from us, as managing his own reactions and the reactions of others was taxing.

Sometimes the case presentations were less complicated: How can I encourage this patient to try medication? Is there anything I can do to get this patient to stop asking for medication? Do you have any ideas as to how we can keep this guy out of the hospital?

Grand Rounds. Grand rounds refers to a lecture on a specific medical topic. It is often considered a “big event” (i.e. lots of people are invited or expected to go). In academic medical centers, someone well-known in the subject usually gives the lecture.

PPOH established a Grand Rounds committee[1. The PPOH Grand Rounds committee was comprised of two people: a senior PPOH psychiatrist and me, as we were both interested in medical education. If you would like me to speak at your Grand Rounds or provide other teaching, let me know.] to organize a series related to homelessness and mental health. Speakers with expertise on schizophrenia, common infections in the homeless, harm reduction, housing first, tobacco use and cessation, and other topics shared their knowledge with us.

These lectures were an essential part of continuing medical education. We need and want to learn so we can provide excellent care for our patients, particularly since there is a dearth of literature for this population.

Peer supervision/support. Every job has its challenges. In psychiatry, it is no different. Working with individuals who have significant mental health problems, homeless or not, can be stressful. Sometimes we feel anger towards patients. Sometimes we feel frustration with other psychiatrists or physicians. Sometimes we feel scared that we did something wrong. Sometimes we worry that our patients will die.

Much of psychiatric training uses the apprenticeship model. While in residency, we meet with “supervisors” (attending psychiatrists) on a regular basis. Supervisors provide coaching and guidance to help residents learn psychotherapy and prescribing practices. This is also where the informal curriculum is taught: Supervisors are essential in teaching (demonstrating) professionalism and attitudes. It is during supervision that we also learn to examine our own reactions to clinical encounters… and, oftentimes, our reactions tell us more about ourselves than about our patients.

I was deeply grateful for these weekly three-hour meetings. (I have since realized that this set-up is rare. No money is gained while physicians are meeting for supervision. Neither patients nor insurance companies are billed. From a financial standpoint, it is wasted time. However, I’d like to think that this investment in physicians ultimately provides benefits for patients. I don’t know if there is any data to support this, though I believe it is absolutely true.) The built-in network of peers gave me security: I knew I could trust them to help me become a better doctor.

Many medical students and residents feel embarrassed to ask questions. They might feel ashamed to say “I don’t know”. With time and experience, that shame goes away. It’s okay if you don’t know. What you do next is what matters: If you need help, ask for it. You will (re)learn something, you will take better care of your patients, and you can then help another doctor in the future.

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Education Homelessness Informal-curriculum Observations Policy

Medicators.

Two recent events inspired this post:

1. My husband and I had dinner at Farestart, which is

… a culinary job training and placement program for homeless and disadvantaged individuals…. As members of [this] community are placed in housing, the need for job-training will play a critical role in ensuring the self-sustainability of these individuals.

While eating the tasty food and learning about the mission of Farestart, I reflected on my experiences working with the homeless. I have encountered them outside of the health care system, in emergency rooms and psychiatric hospitals, and in medical hospitals as a psychiatric consultant.

I realized that, as a group, psychiatrists are skilled at prescribing medications for the homeless. Unlike Farestart, however, we offer little to help the homeless help themselves.

2. Since starting my new job in Seattle, several patients have come to me with the chief complaint[1. “Chief complaint” is a medical phrase that refers to the reason why a patient has come to see a physician. It is not a sardonic comment.] of wanting to stop their psychiatric medication(s).

One of the greatest pleasures of my job is helping people taper off of their medication(s).[2. To be clear, there are instances when I actively discourage people from tapering off of their medications, as some people end up in psychiatric hospitals when they stop taking medications. A personal goal of mine is to help keep patients out of hospitals.] My colleagues and I have all seen patients who are taking large numbers of psychiatric medications for unclear or invalid reasons. There is also data to suggest that certain classes of people are more likely to receive psychiatric diagnoses that may not be valid, which results in prescriptions for medication that they don’t actually need.[3. African Americans are more likely to be diagnosed with schizophrenia. Anecdotally, I’ve worked with several African American patients with diagnoses of schizophrenia who were taking antipsychotic medications, though neither the diagnosis nor the medications seemed indicated. We gradually tapered off the antipsychotic medication and nothing happened. They were fine. Which makes me wonder.]

Some people eventually come off of all of their medications without incident. Some people significantly reduce the number of medications they take. And, unfortunately, a few people end up in the hospital during the tapers.

That never feels good.

I realized, again, that psychiatrists are skilled at prescribing medications, but we know little about stopping medications. (In my brief review of Pubmed, I found only one article that offers suggestions about stopping medications.) Furthermore, as a group, we lack the knowledge about treatments other than medications and psychotherapy.[4. Psychiatrists in private practice are more likely to offer both psychotherapy and medication services. Psychiatrists who work in medical centers often only provide medication services due to the institutions’ financial systems.]

Perhaps this is due to the belief that patients who come to see psychiatrists have already tried everything else. They have gone through trials of exercise, counseling, deep breathing, meditation, naturopathic medications, etc. Because none of that has been helpful, they come to see a psychiatrist as a last resort.

That could be true.

This may be a function of our training. Contemporary psychiatry, for better or for worse, follows the medical model. The medical model focuses on biological causes of illness and disease. Current medical treatments (i.e. medications) aim to correct the presumed underlying biological causes.[5. The underlying biological causes of psychiatric conditions remain unclear. Discussions about “chemical imbalances” are still hypotheses, not theories. Psychotropic medications are primarily empirical treatments.] Thus, psychiatrists end up prescribing medicine because that is what we were trained to do. Furthermore, patients often expect us to prescribe medication. (Like other human beings, psychiatrists sometimes feel the pull to “do something”, even though “doing nothing” may be the most prudent choice.)

Psychiatrists, often rightly so, have reputations as “medicators”. A friend of mine works as a psychiatrist in Canada. She came to the US for fellowship training. An administrator told her that her role in the American clinic was that of “the medicator”. My friend was horrified. Because of the funding system, Canadian psychiatrists routinely provide both medication management and psychotherapy services. She could not believe that her role would be limited to the prescription of medication.

“What? You believe in the biopsychosocial model? You think context matters?” the American fellowship cohort dryly commented.

If the knowledge and practice of psychiatrists is limited solely to medications, of course the general public will believe we are simply “medicators”. This is problematic, as we have incomplete knowledge of how psychotropic medications work. (All psychiatrists should read Healy’s The Antidepressant Era. Healy does not outright dismiss antidepressant medication, but he provides data that strongly argues that antidepressants are not as effective as the public believes.)

I cannot speak for all psychiatrists, but I believe most of us did not choose to enter this field to become “medicators”. Thankfully, many psychologists were involved in my education. I’d like to think that, as a result, I am less inclined to pursue medications as the sole mode of treatment. I must admit, though, that I am unfamiliar with the literature for non-pharmacological treatments. (I am familiar with the literature for housing as treatment…. but what is the evidence—or lack thereof—for exercise? meditation? diet changes?)

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Education Homelessness NYC Policy PPOH

The Homeless Outreach Team.

During my time at PPOH, I spent one and a half days per week with a homeless outreach team.

In 2004, the mayor of New York wanted to reduce the number of people who experience homelessness in the city.[1. Mayor Michael R. Bloomberg Announces Citywide Campaign to End Chronic Homelessness] National data suggests that the vast majority of people who become homeless are only homeless for a short period of time (less than one month) and never become homeless again.[2. From a National Alliance to End Homelessness fact sheet.] Thus, the mayor’s plan focused on people who experience chronic homelessness.[3. “In general, a chronically homeless person is an unaccompanied disabled individual who has been continuously homeless for over one year.”] Of that population, between half to two-thirds of them have significant psychiatric conditions.[3. Page 4-4 of The 2007 National Symposium on Homelessness Research.]

Before describing further details of this plan, let me explain “housing first”:

Traditional housing models for the homeless are built on “merit”. The entry points for housing are generally homeless shelters (which excludes those who are homeless on the streets). Once these individuals connect with housing services, they must follow certain steps to “earn” housing. These steps include regular meetings with staff, taking medications (if indicated) as directed, abstaining from drug and alcohol use, and abiding by other (sometimes arbitrary) rules. Thus, people will only secure housing if they “follow the program”. Unfortunately, many people are unable to “follow the program” (due to psychiatric symptoms, drug and alcohol use, etc.).

“Housing first” is a model where chronically homeless individuals are given housing first. People only need to accept housing.[4. To be clear, people who are enrolled in “housing first” programs are not getting “free” housing. They sign leases, are expected to pay rent, etc. Their rent is generally one-third of their total income. If they receive entitlements, rent is usually taken directly from their monthly cheques.] There are no requirements to take psychiatric medication, to abstain from drugs and alcohol, etc. The underlying premise is people must have homes before they can address their other problems.[5. See Maslow’s hierarchy to learn a view about the importance of housing.] There is evidence that the “housing first” model saves significant health care dollars and improves health outcomes (decrease in number of homeless people; decrease in ER visits and hospitalizations; less time spent in jail).

Major social service agencies in New York City came together to form consortia (consortiums?) to house the chronically homeless according to the “housing first” model. Some agencies built or provided the physical housing; others supplied the staff to work in the residences. Still others provided the manpower to perform actual outreach to the homeless.

Each borough has its own consortium. I was assigned to work on a team in the consortium for Manhattan.

The borough of Manhattan was initially divided into seven sections, though these were ultimately condensed into five. Each section has its own outreach team. The outreach team I worked with was comprised of:

  • a program director (social worker)
  • a team leader (social worker)
  • five housing workers (high school graduates to social workers)
  • a receptionist (who also answered 311 calls about homeless individuals in Manhattan)
  • and a psychiatrist (me)

The section we worked in was bounded by the southern tip of Manhattan, the East River, the Hudson River, and Houston Street. Our job, as a group, was to identify chronically homeless individuals, build rapport and encourage them to accept housing, and shepherd them through the housing process until they moved in.

Two of the housing workers were on duty from 5:30am to 1:30pm. They would travel throughout our designated section, either by car or on foot, and seek out people who were “bedded down”—those individuals who were sleeping on the street (or in other public spaces). After rousing people and introducing themselves, the workers would ask for homeless histories to learn if people were eligible for the program. If the individuals could tolerate it, the workers would then start to build rapport with the ultimate goal of encouraging them to accept housing.

You can imagine the reception they often got. Few people want their sleep disturbed, let alone by strangers. Furthermore, homeless individuals are only too familiar with police officers and people with malicious intent waking them while they are sleeping.

Housing workers who worked the day shift from 9:30am to 5:30pm also engaged in outreach, though they generally worked with homeless individuals who had already established connections with the team. They often helped people secure birth certificates, identification, and entitlements. They accompanied individuals on housing interviews, provided transportation for appointments, and advocated for them in various contexts.

There were also evening and overnight teams, though I never worked with them directly.

The team leader and program director provided supervision and support for the rest of the team. They also compiled data about housing placements. The more people a team housed, the more funding that team would receive. Despite the productivity expectation, we reminded ourselves that these people were people, not merely numbers.

The psychiatrist’s official job was to administer psychiatric diagnostic interviews to determine if the person had any psychiatric or substance use disorders. The diagnosis (or lack of one) would determine what type of housing the person was eligible for. (There were always more people than available housing. Yes, this is where a psychiatrist can become an agent of social control. More about this later.) Though I could meet with people in the office for interviews, I often went out with different workers to talk with people wherever they were. (Some people had significant psychiatric symptoms that interfered with their ability to meet anyone at a specific time or place, so I would often find them in subway stations, in public parks, behind garbage bins, on stoops, etc.)

I also provided education to the outreach workers, did regular outreach myself with a few clients whose psychiatric symptoms (often delusions) interfered with their ability to even consider housing, and provided informal supervision to the staff members. These housing workers, particularly the ones who work early in the morning, have tiring and often thankless job.

Of all the positions I had at PPOH, this was by far the most challenging for psychological and ethical reasons. Some people had severe psychiatric conditions. Many individuals lived in squalor. A lot of people experienced terrible things at the hands of their fellow human beings. People suffered.

As a team, we interacted with a lot of people. These included not only homeless individuals, but also police officers, ambulance crews, emergency rooms, hospitals, private property owners, homeless shelters, medical clinics, government agencies, staff at supportive residences, and the general public. Working with and in all of these different systems was often taxing and frustrating. Everyone in all these different arenas wanted to do “the right thing”, except people often had contradictory ideas as to what “the right thing” was.

In this position, I witnessed human dignity, creativity, and resilience. No one wants to be homeless. Many homeless people, whether they have psychiatric conditions or not, feel shame about their circumstances. They want things to be different, but they don’t know what to do. They try their best with what they’ve got. Sometimes their strategies work, sometimes they don’t. We can all recognize that in ourselves. And that’s how the line between “us” and “them” dissolves.