As we all attempt to find our new normal after years of pandemic living, it’s evident that this will involve an immense societal need to focus on individual mental health. With nearly one in five adults living with a mental illness, finding innovative new approaches to diagnosis, treatment, and prevention are crucial to improving the lives of millions of people. Investigators at the Mass General Research Institute are working to do just that.
This week, we talked to Katherine Koh, MD, a practicing psychiatrist at Mass General Hospital and a member of the Street Team at the Boston Health Care for the Homeless Program.
Can you briefly describe the state of the mental health of homeless populations?
Few populations bear a greater psychiatric burden than the homeless population. Studies suggest that a staggering 76% of the homeless population has a mental illness. Mental illness and homelessness have a bi-directional relationship, in that it is not just that mental illness is a risk factor for becoming homeless, but also homelessness is a risk factor for mental illness because the trauma experienced while homeless can lead to mood disorders, trauma-related disorders and substance use disorders.
Dr. Koh is part of the Boston Health Care for the Homeless Street Team, which provides face-to-face medical care for individuals who are homeless and sleep on the street. This group is known as Boston’s “rough sleepers,” and they commonly face conditions such as extreme weather, violence, and trauma.
What is the biggest barrier right now to homeless individuals receiving the necessary mental health care services they need?
I would say the lack of proactive outreach models to reach this population. So many people experiencing homelessness have had unimaginable trauma in their early life, which understandably leads them to have difficulty trusting healthcare professionals. In addition, many have had prior negative experiences with the healthcare system.
Also, some have difficulty with insight, or understanding the mental health symptoms they experience, and therefore prioritize other needs over their mental health. As a result, people often do not seek care on their own from more traditional clinical settings. It is therefore critical that we design and implement more proactive outreach models such as street outreach or clinics embedded in places like homeless shelters, to bring care to people who may not be receiving it otherwise.
In your recent paper, you mention three aspects to creating a better mental health care system for homeless individuals, can you briefly describe those?
I think the three pillars of an ideal mental health system for homeless individuals include preventive, community, and facility-based services. Prevention is critical as so often the focus is on housing those who are already homeless, but in order to truly nip this major crisis in the bud we have to start further upstream and focus on reducing the factors that lead people to become homeless in the first place, including lack of affordable housing, cost and capacity barriers to mental health care, racial inequities, and adverse childhood experiences.
For those who do become homeless, community-based services are essential, including street outreach, shelter-based care, and evidence-based models of care that improve outcomes for this population, including interdisciplinary, intensive teams such as assertive community treatment (ACT), and Housing First, which provides access to supportive housing without precondition.
Finally, for those who are most severely mentally ill, we need more compassionate, humane inpatient facilities that focus on recovery so that these individuals can ultimately thrive in the community.
Community building: How do you build a sustainable community for institutionalized individuals, especially if they were previously homeless and more than likely have no support system?
One of the most beautiful things about being a street psychiatrist is witnessing the community that forms on the streets. People develop strong ties with one another, including friendship, romantic relationships, and everything in between. Thus, although many of these individuals do not have a lot of family or outside support, the human need for companionship is strong and people are able to create bonds with one another over time.
In the same light, a focus on community-building within facilities, with the right support and structure, can create bonds between people. I think encouraging peer mentoring, strength-building exercises, group bonding activities, or having unstructured time to socialize within these facilities are all ideas that can help create relationships that are central to healing.
Compassionate care: Can you discuss this concept of Schwartz Rounds as a means for creating more compassionate care in mental health facilities?
Schwartz Rounds offers healthcare staff a regularly scheduled time to discuss the social and emotional issues they face in caring for patients. As opposed to traditional medical rounds, the purpose of Schwartz Rounds is to focus on the human dimensions of medicine. These rounds have been shown to decrease feelings of stress and isolation and increase feelings of compassion toward patients and colleagues. This practice is becoming more commonplace within medicine, and is a concrete example of how to encourage a culture of recovery and compassion in mental health facilities.
Reintegration: Can you briefly describe a successful reintegration system for those who were previously homeless, but have received inpatient care for mental illness?
I think the key is having a plan in the community for when patients get discharged from the hospital to make sure they don’t go back out onto the street. For example, MGH and Boston Health Care for the Homeless Program have a strong partnership that often facilitates this care coordination. I often get called by the inpatient psychiatric unit when a patient on our team is admitted to the hospital because they are flagged in the chart as a street team patient.
We also always try to make a plan for how a person will get follow-up care after discharge. If a patient experiencing homelessness does not already have a team to care for them, we have had “warm handoffs” where an inpatient staff member will walk the patient straight down to our outpatient clinic at MGH upon discharge for an appointment, a system we are working to develop further.
This is an example of strong collaboration between hospitals and community programs that facilitate high-quality care for this population. The goal is for gains made during inpatient hospitalization to be sustained after leaving the hospital.
How do you determine a need for involuntary hospitalization of those with severe decision-impairing mental illness?
This is an excellent and difficult question, as the line is often gray, and there is a range of opinions about this question depending on who you ask.
For me, I tend to think if a person is acting in ways that are inflicting severe harm on themselves or putting themselves at risk for death, involuntary hospitalization is warranted.
Sometimes, involuntary commitment is the compassionate thing to do to protect a person from further harm or loss of life. For instance, a person who is wearing no clothes in freezing weather, or multiple winter coats on a sweltering hot summer day often needs involuntary hospitalization in order to prevent death.
However, often time the cases are not so clear, and it is an accumulation of evidence, speaking with other people who have interacted with the person, and observation over time that can make the determination. It is also critically important that if involuntary commitment is pursued, that it is done with the least force possible and for the minimum amount of time possible. As mentioned, there also should be a clear plan for where the person will go after hospitalization to make the commitment most worthwhile for the patient.
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