FIG1 I started my rotation at the
Homeless Outreach Team (HOT) on a very cold Tuesday in January. The HOT
clinical program provides case management to the chronic homeless population
who live on the streets of the Bronx, N.Y.
Outreach workers and case managers canvass the streets of the Bronx 24
hours a day, seven days a week, providing assistance with basic needs such as
food and linkages to mental health, substance abuse, and medical services,
with the ultimate goal being placement in permanent housing.
After taking the D train a few stops past Yankee Stadium, I met the program
director in the dark basement office of the HOT headquarters.
Following a brief orientation, I was informed that I would be accompanying
two case managers in the field to begin immediately seeing clients among the
homeless population. Armed with a handful of charts, I was ready to begin. The
case managers who rode in the van with me were extremely friendly. As a PGY-3
resident, my heart was beating in anticipation of what was going to happen
next. I guess they noticed the perspiration, which defied the cold weather,
trickling down my forehead as we approached my first homeless client. They
assured me that I would be fine.
The first homeless person we encountered was sprawling on the steps outside
the number 5 train station, soaked with his own urine. He appeared guarded
when I approached him for the history. Since the case managers were familiar
to him, I was able to engage him and establish rapport. Besides being a
chronic alcoholic and homeless for 20 years, he had been hospitalized numerous
times for schizophrenia. The case manager later told me that this client
always presented a challenge because of his inability to complete a short-term
detoxification program. The team had taken him to detox programs on many
occasions, yet after only a couple of days he ended up back on the streets.
Luckily, because of the cold, he agreed to go to the shelter on that day.
It doesn't always work that way. Sometimes the case managers have to accept
that the client wants to remain on the streets. Client-worker relationships
are built gradually on trust and are easily broken if a case manager pushes
too hard or too fast.
I asked the case manager if she felt frustrated when homeless clients
continually refuse assistance or return to the streets. She said that her
reason for doing this job was because she cared and that managing one's own
feelings is an essential skill for anyone who works with this population. She
quickly added that the outreach team has helped hundreds of people get off the
streets and into housing, where they gain stability and are encouraged to
re-enter the community as productive members of society.
During my six-month rotation, I learned that there is limited access to
appropriate mental health care for the homeless community. The borough has
only one dropin center that provides services, and overnight shelters do not
have the capacity to provide mental health care.
I also learned that on any given night in New York City, approximately
30,000 people are homeless. An estimated 30 percent to 50 percent of them have
mental illness. These individuals typically do not have strong social
supports, and their symptomatology precipitates disruptions in relationships
that often contribute to homelessness. Such symptomatology can also translate
into an inability to seek help.
There is a severe shortage of psychiatrists providing care to homeless
individuals. That shortage and the resistance of many homeless individuals to
seeking treatment have created an acute problem for providers of homeless
services. Psychiatry residency programs have the opportunity to address the
shortage by encouraging psychiatry residents to work with homeless individuals
early in their career. This would help alleviate the acute shortage and
provide a valuable learning experience for residents.
Throughout my rotation at HOT, I was encouraged to focus on the important
issues that emerge for psychiatrists working with the homeless. This
experience confirms my passion for the well-being and welfare of the homeless
population. Without this component in my psychiatric training, I never would
have been exposed to such a challenging and "real" setting. This
experience added a new dimension to my studies and greatly expanded my