Unidentified white homeless female. That was how she was first known to me
in the holding room of the psychiatric emergency room.
She was too psychotic to be able to tell anyone her name, and when I came
on shift, I was both fascinated by the mystery she presented and excited by
the connection with my new work with Boston's homeless mentally ill
population. I determinedly searched through her bag of reeking belongings
looking in vain for some form of identification. I contacted my new colleagues
on the medical team who worked with the homeless. They recognized her but did
not know who she was.
Department of Mental Health outreach workers were called, and then shelter
outreach workers; all recognized our patient but knew nothing about her. The
following day the unidentified white homeless female, who had denied
suicidality, was discharged.
Not surprisingly, she returned to the ER, and on my next ER shift a couple
of weeks later, she was again in a holding room.
Only this time she had a name—and a medical-record number, a history,
and a desperate sister. Since I'd last seen her, she had been hospitalized at
a local hospital that now refused to readmit her because it was not granted
the commitment it had requested last time she was there. Her sister said she
was a "perfect lady" when following a treatment regimen, in stark
contrast to the threatening, fire-setting woman she became when ill. The
sister was trying to pursue guardianship but needed a doctor's corroboration.
She had never heard of the National Alliance on Mental Illness (NAMI) or the
Program for Assertive Community Treatment (PACT).
The now-identified homeless woman waited an entire weekend in our emergency
room. This is not, I am well aware, an uncommon situation. Yet the
juxtapositioning of these two visits to the ER and the tragedy of an ER visit
that might well have been longer than her last hospitalization started gnawing
How, I wondered, could as vulnerable and ill a person as this woman be left
so completely out of our mental health system? Who exactly was our system for,
if not this "perfect lady"?
I pushed hard for admission. I told her sister about resources such as NAMI
and PACT and encouraged her initial efforts at pursuing guardianship.
But what, I had to wonder, was her actual chance of becoming more healthy
as a result of this particular encounter with the mental health system? It
depended critically on the persistence of particular individuals: after my
shift ended the ER residents and staff continued to push for her to be
admitted, and an inpatient attending was willing to take administrative heat
about getting her a hospital stay that was more than three days long. She was
also fortunate that she had a sister able to follow through on the hard work
of gaining a piece of the resource-limited pie.
What we have to offer people such as this woman is not, in fact, a system.
Successful treatment that is so dependent on the above-and-beyond work of
dedicated individuals is not a solution. It is, instead, a personal means of
addressing a very public problem; there is nothing in such an intervention
that is replicable. Dedicated, caring people are without a doubt an essential
ingredient; they are not, however, sufficient to substitute for a reformed
system of care in which this woman could begin to get the care she needs.
In the absence of such a structure, I felt only frustration. If her recent
history is any guide, my patient's situation was anything but promising. Even
while discussing guardianship and PACT with my patient's sister, I knew that
it was far more likely that the now-identified "homeless white
female," after more than 60 hours in a locked holding room, would be
admitted only briefly, if at all.
Luckily for me, if not for her, I'll likely have the continuity of getting
to see her again, with the homeless outreach team on its weekly walking rounds
of the streets of Boston. ▪