Homeless, not hopeless: 4 strategies for successful interventions
Treating homeless mentally ill persons in a community-based setting—such as an inpatient medical or psychiatric unit, emergency department, or shelter clinic—requires special clinical adaptations. Four strategies can help achieve a successful intervention.
1. Engage patiently. Many homeless persons view the mental health care system with suspicion and apprehension. Meaningful engagement often develops slowly;1 you could see a patient for weeks or months before he or she accepts treatment. Empathy and persuasion may be your most important therapeutic skills during initial encounters.
2. Assess needs broadly. During the initial evaluation ask about basic needs (safety, food, clothing, and emergency shelter) as well as psychiatric symptoms. Understandably, the homeless patient may place a much higher priority on food and shelter than on mental health services.2
Successful psychiatric treatment will be difficult if the person has no stable access to shelter. Make sure a workable strategy to obtain emergency, transitional, or permanent housing is in place.3 Work closely with the hospital’s social worker or the shelter’s case managers to facilitate this process.
3. Shape interventions pragmatically. To prevent the chaos of a shelter or the street from thwarting even a basic intervention:
- provide psychotropic samples rather than written prescriptions
- simplify dosing regimens to once-daily
- help the patient develop safe storage strategies for medications to prevent theft and exposure. For example, provide pill boxes or blister packs, or request that the shelter’s case manager store pills for the patient.
4. Retain arduously. Don’t expect perfect cooperation. Expect treatment nonadherence, lost or stolen medications, missed appointments, sporadic follow-through with other services, and inconsistency in abstaining from alcohol or other substances of abuse.
Set limits and establish consequences to keep a homeless person in treatment rather than to justify termination. For instance, if the patient repeatedly “loses” her medications, then provide just a few days’ supply at a time. This strategy encourages frequent follow-up and monitoring, which is more effective than discharging the patient for “noncompliance.”
1. Rowe M, Hoge MA, Fisk D. Critical issues in serving people who are homeless and mentally ill. Adm Ment Health 1996;23(6):555-65.
2. Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Pub Health 1997;87(2):217-20.
3. McQuistion H, Finnerty M, Hirschowitz J, Susser E. Challenges for psychiatry in serving homeless people with psychiatric disorders. Psychiatr Serv 2003;54(5):669-76.
Dr. Christensen is associate professor of psychiatry, University of Florida College Medicine, Jacksonville, and director of the university’s community psychiatry program.