Richard Doan is a Psychiatrist with Inner City Health Associates and Assistant Professor of Psychiatry at the University of Toronto in Toronto, Ontario
In Toronto’s first week of true winter weather, two homeless men died on the street, one in a bus shelter in the city’s most public square. He was wearing only jeans, a t-shirt and a hospital identification bracelet.
My street outreach teammates and I saw a slight, older woman who had literally been living in a box for months.* The box was about 6 feet long, 4 feet wide and 3 feet high and was covered by a blue plastic tarp. Her furnishings consisted of a few blankets. The “dwelling” was in an alleyway just behind some shops. The lady was disinterested in any form of housing or treatment and never accessed shelters: she always slept in her box. She repeatedly said that she would soon be moving to a Caribbean island. During a particularly bitter cold spell, we became concerned with her safety, and I completed a form for involuntary psychiatric assessment. The emergency department psychiatrist agreed with me that she likely had chronic schizophrenia, but the client was calm and would not take any medication. She promised the emergency department staff that she would go to a shelter if she was discharged. We made it clear that she was unlikely to do so, but after one night in emergency she was given a subway token to go to a shelter. She disappeared and was lost to follow-up.
How does this happen? How does the medical system both help and hinder the progress of people who are homeless?
Physicians often have an unduly pessimistic view of the prognosis of homeless people, particularly those with addiction and mental health issues. Some hospital staff members seem annoyed by their presentation. These staff members question the role of psychiatric admission in assisting these clients to find housing and to live better despite dealing with severe mental illness. Psychiatrists sometimes seem to hide behind the Mental Health Act, feeling that clients are likely to successfully mount a legal challenge to an involuntary admission to hospital or a finding of incompetence to consent to treatment. Admission can seem to be a game of chance, depending on the hospital, the psychiatrist is on call and whether beds are available – factors external to the client and his or her situation. Lack of admission and inpatient treatment carries substantial risks, not the least of which is the abrupt loss of a working relationship with outreach caregivers.
Most physicians are personally and professionally unfamiliar with life on the street. Exposure to homeless health issues is limited during medical training, and only infrequently involves meeting with homeless clients in their living environment. Physicians usually see such patients when they are acutely ill and distressed — one feels precious little sense of client progress or success.
In our experience, psychiatric admissions of adequate duration play a critical role in helping a homeless person get off the streets. We have seen that for our clients living with a psychotic disorder, those who are admitted to hospital are more likely than those who are not to secure housing postdischarge. Such success is born of the synergistic, collaborative efforts of inpatient psychiatrists and mental health staff and our outreach team. Providing housing and income support expertise to patients in hospital at risk of homelessness decreases the chance of being discharged to a shelter or the street.
Of course, our goal should be to prevent crises rather to respond only after they occur. A housing-first approach, as opposed to treatment-first or housing-readiness models, that provides continuous, practical support to recently homeless clients has repeatedly been shown to be effective, including in a Canadian context. Similarly, intensive case management coupled with permanent housing is more effective than either program type on its own. The Assertive Community Treatment model of comprehensive psychosocial care has been successfully adapted to the homeless population, leading to decreased homelessness, less time incarcerated, and fewer psychiatric admissions with remarkable cost savings. Our multidisciplinary team is able to find a permanent address for just over half of our clients, all of whom live with severe mental illness or substance addiction.
Many successes come with patience and collaboration, and some of these are truly joyous. Several years ago, we housed a lady with severe mental illness who had been on the street for more than one third of her life, enduring theft, degrading assaults and severe winters. After a prolonged stay on a psychiatry unit, she took possession of a tidy geared-to-income apartment. Her pride and happiness were obvious during our coffee date with her in her new home. Medicine is rarely so rewarding.
*Details have been changed to protect the identity and privacy of the patient.