Angela wrote to Jim Withers the following (Feb 22, 2007)

Hi Jim

I would liek to pick your brains about a group of entrenched rough
sleepers that there is in Westminster.

Apparently, they are resistant to engagement but thought, by the
local mental health team, to not have 'significant' mental illness to
a level that would justify compulsory admission for assessment.

I would be interested to hear how you manage this in Pittsburgh....do
psychiatrists do street outreach? If so, do they go first, or do you
go first and make a preliminary assessment? Do you have any outreach
psychologists / therapists?

Your experiences would be very useful in deciding on the best
approach for this 'resistant' group...

Thanks


Angela








Hi Angela - it is a very significant area. (so many to talk about!) I always wonder why the people who need psychiatrists and the psychiatrists never seem to be at the same place. Maybe psychiatrists are largely in a "defense mode" and therefore would not feel comfortable getting out into the wild and wooley streets where the control is not in their hands. It is (ironically) very rare that a psychiatrist in the US seems to be willing to become part of street work. Jim O'Connell's team has a full time street psychiatrist, and there is one in Chicago who works with their large needle exchange program. (she's a character) We have not been able to lure one into the streets - even by paying them. There is one very cool psychiatrist who will now go out with us is we really need her. She was one of my medical students earlier. (I think we have to make street physicians ourselves!)

Anyway - this question would be another outstanding issue for the next Smposium. The psychiatry world there sounds like the one here. There's a gap between those who are inclined or forced into treatment - and those who not "sick enough" (but definitely need help!) I think it is also true in general medical practice where some of the most psychiatrically needy folks won't ever go willingly to a psychiatrist. There's a whole sub-group of patients that we generalists have more experience with than the "experts". And even more so in the rich frontier of the streets! Even the few texts I have read on "street psychiatry" are geared towards drop-in centers and more controlled encounters than our outdoor work.

There's a monsterous amount of fascinating work to be done out there with the "stable" psychological issues. When a person starts to get in the "donger to self or others" zone, we make a focused plan for him in terms of outreach connection, observation and discussions. Having key people in the giant psychiatry system - who we can call and they will take us seriously - is essential. We do not like to do the commitment ourselves since the person will likely be "treated" and released within a couple days - then we have to try to establish some kind of rapport again. Sometimes we just do it anyway. Our regular nurses are often from psychiatry backgrounds and this helps both in terms of the assessment and the connections we need to make. The severe winter always helps make the case. Summer is much harder. There is a Crisis Team that can be called, but they are highly geared towards the strict legal interpretation of committing people involuntarily. I can't blame them because if the judge just overturns it, they get grief from their bosses. By working with the Crisis Team we have made things a little better. We've made progress in the initial "getting them into help" part, but the hard work is in the treatment plan. Even though we have worked for years with a person - as soon as they are int eh psychiatry hospital the team there will usually not talk to us in order to defend the patient's privacy. We have snoop around to see if they are released, then try to guess what we can do to help with a plan. I suspect other cities have a much better relationship than we do in Pittsburgh. We have a new full time nurse who used to be in the government oversight of the psychiatry system and I think we will soon be able to improve coordination of care...

A lot of time we practice what I call "vulture" medicine. We kind of sit on a branch and wait until they drop, then pick up the pieces. I guess we are also doing lots of relatinship efforts, etc - but not anything big until they fall into a more classic willing-to-accept-treatment or danger-to-self category. Rarely, we are able to get them onto psych meds in the street and they might improve. The folks out there are clearly "self selected" to fall through easy treatment plans.

For the most part, we have learned to work with the street level of different kinds of mental illness. The connection is always one of trust and respect - after which we have at least a chance of working with folks. We find out the "outposts" where psychiarists are willing to have homeless people come and make that transition as smooth as possible. I really think we are as much a service to the medical psychiatric community as we are to the homeless since we can "translate" one reality to another. Alternately, as I'm sure you've experienced, there is nothing worse than working long and hard to get someone into a psychiatric appointment - then having them treated with disrespect and never going back. I call it the "fiance conundrum". You love you fiance, you love your parents, but they don't understand each other.....

Anyway - did I answer you question? I think Boston has one of the better systems, but I am going to transplant this to the streetmedicine web site and see if anyone comments.

Jim