Category: PPOH

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Education Nonfiction NYC Observations PPOH

Daily Schedule: Assertive Community Treatment.

A sample agenda as the consulting psychiatrist with an assertive community treatment (ACT) team:

7:55am. No one is at the office yet. Insert a key into the gate in front of the building. The gate makes grating and squeaking sounds as it rolls up. After entering the building, quickly disable the alarm, lock the door on the way in, and roll the gate back down. From the medication room, pack into a brown paper bag a pair of gloves, two alcohol pads, one band-aid, a pinch of 2×2 gauzes, a portable sharps disposal container, and a pocket-sized bottle of hand sanitizer. Unlock a different cabinet and fish out a small box that contains liquid haloperidol decanoate, a long-acting antipsychotic medication. Drop that into the brown paper bag.

Leave the office, secure the building, and make sure that the gate is rolled completely down before walking away.

8:40am. Arrive at a patient’s[1. All patients described here are composites of people I have seen across time.] apartment uptown. She lives with her mother, grandmother, and her mother’s boyfriend. As usual, she’s still sleeping, even though she knew that this visit would occur around 8:45am. She’s wearing a strappy tank top and baggy pajama pants. She rubs the sleep form her eyes. She walks back into her bedroom. An electronic rose is in the corner next to her mirror. Different colored lipsticks are on the table. There is a desk lamp on the nightstand, as well as several magazines.

She shrugs her shoulders after realizing that her offer of a seat on the unmade bed was politely declined. She’s doing pretty well: She’s re-enrolled in GED classes and is studying to take the test, though she’s finding the math portions difficult. She’s still going to the local bar on weekends, but denies getting drunk. When she also denies smoking marijuana, her response seems honest, though her next visit to the office will include a urine drug screen test. The antipsychotic medication isn’t causing side effects. She asks for advice on how to avoid bad boyfriends.

9:30am. Arrive at the second patient’s apartment after a subway ride further uptown. He lives with his elderly parents. He’s not doing well. He yells at his mother and his father often locks himself in the bedroom so they don’t have to interact.

He begins to share that he is dating a woman, then suddenly comments that he hasn’t drank any alcohol in months. His mother interjects and says that he has come home very late at night smelling of alcohol. The stories from the past week spill from her mouth; she’s watched him cross and re-cross the same street for two consecutive hours. Sometimes he yells about the gods who have failed him. Small items—vases, salt and pepper shakers, silverware—have started to go missing from the apartment.

He says he’s taking his medications, but his mother says that she finds pills in the trash cans. He mumbles under his breath.

No, she hasn’t had to nor wanted to call the police. No, he doesn’t want to go to the hospital. He’s eating the ham and cheese sandwich that she’s made for him. She asks what will happen next.

“If you feel unsafe, call 911 and call the ACT team. Don’t wait. Just call. We’re all worried about him.”

He rolls his eyes and asks the wall why anyone would think he would hurt anyone. He doesn’t seem to remember that the last time he developed symptoms and drank alcohol, he punched his daughter.

10:40am. Arrive at the third patient’s apartment after a bus ride across town. He’s an elderly man who believes that his neighbors have stolen his internal organs and that cannibals will eat him if he leaves the building. These beliefs as well as gait problems keep him in his apartment. This is the person who will receive the haloperidol injection.

The usual conversation about his medication ensues. He’s willing to accept the medication, but wants to discuss again why it is at its current dose. The reasons haven’t changed from last month. He nods in what seems to be understanding, though then asks, “The medication will not make my skin turn blue, right?”

This is a significant improvement from a year ago.

Three large cockroaches skitter across the countertop. Two empty cartons of orange juice sit on the kitchen table. He looks into the living room, which holds his bed. He doesn’t go into the bedroom anymore. He still cries when he thinks about his dead wife.

He rolls up his sleeve and looks at his arm when he receives the injection.

“It never hurts when you do it.” He’s probably just being nice.

11:45am. Arrive back at the office. A patient sits on the curb, smoking a cigarette, while chatting up a cab driver. Everyone says hello to each other.

11:50am. Two of the social workers are in the office. They and the secretary all share events from the morning. One of the ACT patients may leave the hospital tomorrow. One of the social workers will escort him directly from the hospital back to the apartment if the hospital discharges the patient.

“I’ll visit your guy tomorrow morning,” the other social worker says, referring to the second patient who lives with his elderly parents. “We’ll check in with him every day this week.”

12:00pm. Work on documentation from the morning visits. Mindlessly eat lunch.

12:53pm. Fourth patient arrives for his 1pm appointment. He greets everyone with a warm smile.

He recently started volunteering at the library and teaches young children how to read. He rides his bicycle around Central Park to help keep his blood sugars under better control. His daughter is coming to visit for the holiday. He plans to cook salmon for dinner tonight. He’d rather have fried chicken.

“I’m scared to lower my medication, Doc,” he says. “I don’t want to end up at the hospital again. But if you think all this weight gain might be from the medicine, I guess we could try it—you said real slow, right?”

After some more discussion, he concludes, “No, let’s not change the medicine now. Lemme get through the holidays and then we’ll try. Real slow. Real slow.”

His wishes are honored without argument.

2:00pm. The fifth patient hasn’t arrived.

2:10pm. The fifth patient still hasn’t arrived. She’s more organized than people might initially believe, but she’s rarely punctual.

2:17pm. “Heya doc, how you doing, how you doing,” the fifth patient says, flopping down on the seat. She’s chewing on a popsicle stick. She’s tied the two ends of a necktie together and is wearing that around her neck like a necklace. Four other neckties are tied around her neck the same way. Ear phones cover her ears, but they’re not plugged into anything. Her striped socks are pulled over her baggy sweatpants.

“Heya doc, how you doing, how you doing, the vapor’s hot today, so hot. The icicles bring down the vapor, the vapor pulls the magnet and the poles spin, they spin, that’s what makes the Earth spin, the vapor around the Earth spins, too, spins like a record, so cool, so cool….”

She just finished her first week as the filing clerk for the drop-in center. The staff there said that she did good work and that she seems to like it, but she occasionally breaks out into song.

“Do you like your new job?”

“Yes, yes, but I want them to like my new job, too. I like the money, too, I can buy myself some new shoes, new blue shoes, new blue frue true krue shoes, so krue, so cruel, cruel world.”

On the way out, she flings the popsicle stick into the trashcan and belts out, “NEW YOOOOORK… CONCRETE JUNGLES WHERE DREAMS ARE MADE OF….”

3:05pm. Sixth patient arrives. He sits down and looks out the office window into the lobby. Everyone said hi to him as he walked in. He didn’t respond.

He doesn’t say anything in the room. He doesn’t make any eye contact. He examines his nails. He reties his shoelaces. He rolls up his pant legs. He strokes his beard. He fishes a half-smoked cigarette out of his pocket, then puts it back in.

“What’s going on? Is something wrong?”

He sighs and shakes his head. He gets up and doesn’t look up in acknowledgment when he hears entreaties to stay. As he walks out of the office, he finally says, “I’ll be back.”

3:20pm. Ask one of the social workers to follow the Tacit Man out of the building with hopes that they will have a conversation.

3:22pm. Watch from the lobby while the social worker and the Tacit Man talk. They’re actually speaking to each other.

3:25pm. The social worker walks back into the building and the Tacit Man walks across the street.

“Tacit Man is fine, just having a bad day,” the social worker says. “He’ll come back tomorrow to see you, same time.”

“Thank you!”

3:27pm. Call patients to remind them of meetings scheduled for tomorrow. Most of them answer their phones.

3:45pm. Resume documentation with occasional interruptions from other patients wandering into the office to say hello.

4:35pm. Coordinate plans with the social workers for tomorrow. Discuss medication changes, medication deliveries, and which patients need closer monitoring.

4:45pm. Leave the office. That same client who was sitting on the curb and smoking is still sitting on the curb and smoking. He waves hello. I wave back.

Categories
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.

Categories
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.

Categories
Education Lessons NYC Policy PPOH

Assertive Community Treatment.

While at PPOH, I spent two days a week working with an Assertive Community Treatment (ACT) team.

ACT is somewhat like a psychiatric hospital outside of a hospital. It is an evidence-based practice[1. From the New York State Office of Mental Health: “When comparing recipients before and after receiving ACT services, studies have shown ACT recipients experience greater reductions in psychiatric hospitalization rates, emergency room visits and higher levels of housing stability after receiving ACT services. Research has also shown that ACT is more satisfactory to recipients and their families and is no more expensive than other types of community-based care.”] that features a multidisciplinary team (social workers, psychologists, psychiatrists, nurses, case workers) that works with a small group of patients who often experience impairing psychiatric symptoms. It provides comprehensive and flexible psychiatric services. All of the care occurs in the community.

The ACT team I worked on was staffed with:

  • one program director (social worker)
  • one team leader (social worker)
  • one MICA (“mental illness and chemical addiction”) specialist (social worker)
  • one vocational specialist (social worker)
  • one entitlements specialist (almost-graduate from social work school)
  • two case workers (one who had recently earned a social work degree)
  • one registered nurse
  • one secretary (who did much more than clerical work)
  • two psychiatrists (our combined hours did not fill a full-time position)

During my time there, I provided care for about 35 patients. (The other psychiatrist provided care for the other 35 patients.) The staff to patient ratio is purposely kept low, as ACT is considered an intensive intervention.

Patients who are referred for ACT services must have been psychiatrically hospitalized (often involuntarily) at least four times in the past year. They often have multiple emergency room or mobile crisis visits. Other outpatient services have often failed or have been insufficient to prevent crises and hospitalizations.

Thus, a chief goal of ACT is to keep people out of the hospital.

The ACT model dictates that the team (as a whole) must make a total of at least six contacts with each client[2. There is a movement in mental health—and in other parts of medicine—to move away from the term “patient”. In this particular ACT setting, patients were called “clients”. Sometimes they are called “consumers”.] every month, preferably in the community. One of these visits should be a meeting with the psychiatrist. Some patients regularly came to the office for their visits. Others, however, could not or would not come in. We thus went out to them. (Hence the adjective “assertive”, which, in some cases, could be construed as “coercive”. More about coercion later.)

If I did not see patients in the office, I often saw them in their apartments. (Limits and boundaries do not blur, but they certainly shift. My experiences in these residential settings inspired this post. To be clear, there were a few individuals who I never met alone. I insisted they meet me outside or in the clinic. Some of this was due to their past behaviors; some of this was my gut instinct.) For those who did not feel comfortable meeting in their apartments, we met in lobbies, parks, or chatted during walks. (During my time on ACT, I came to value talking and walking as a therapeutic intervention.)

ACT was formerly deemed “long term care”; some patients have been on ACT teams for over a decade. (This is often due to repeated psychiatric hospitalizations despite ACT services.) Most of the patients had psychotic disorders (such as schizophrenia) and, surprisingly, many of them had actively involved family members. I suspect that this impacted who was referred to ACT; family members were often the ones bringing people to the hospital for care (versus calling the police, etc.) Most patients “graduate” from ACT within a few years: They stay out of the hospital, become more involved in the community, and no longer need that level of care.

I learned in this position that people with chronic psychotic disorders can get better. Their symptoms decrease. They learn how to temper their behavior so that they do not attract undue attention while out in the community. They set and reach personal goals, like earning high school and college degrees, securing employment, getting sober from alcohol and drugs, and taking care of their physical health. They stop smoking! Sometimes they need a lot of support and a number of years need to pass before things settle down, but people with diagnoses of schizophrenia are not doomed to a life of poverty and “low function”.[3. The public rarely hears about positive outcomes for people with schizophrenia. There is research that suggests that a significant number of people with diagnoses of schizophrenia either experience improvement or recovery of their condition. Anecdotally, I agree.]

I also learned the importance of seeing patients in their environments. So much of contemporary medicine now occurs outside of a person’s living situation. That is often appropriate and fair (e.g. patients shouldn’t undergo surgery in their own homes). Because of the intimate nature of medicine, meeting in a “third” location can help preserve privacy and security. However, we can learn so much about how people function (or do not function) when we see their living spaces. We also realize strengths that we would otherwise overlook. A neat home, a sack full of old prescription pills, vinyl records of classical music, papers all over the floor, photographs of friends and family, roaches climbing over dozens of empty cans of soda: All of that is information that doctors often never have.

It is amazing how people live their lives. It is remarkable how much people will tolerate. And it is humbling that people are willing to share their lives with you.

Categories
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.