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Psychiatry on Wheels: A Narrative for the Case of Street Medicine From a Housing Perspective
By Franco Bejarano, MSW, LMSW

It's Thursday night as I step off the bus parked under a dimmed yellow streetlight illuminating the dark parking lot of an abandoned church. "Are we ready?" I ask the team of six that follow behind me, as we approach the dark alleyway on the side of the dilapidated building. It's a chilly early-winter night. You can hear the humming of cars in the distance from a major interstate nearby, as well as the faint sounds of occasional ambulances from the city's main hospital a few blocks away. We are a street medicine team. There's the psychiatrist, the nurse practitioner, a small group of medical and nursing students, and me, the social worker. We approach the darkness with only flashlights, blankets, and a few backpacks filled with necessities as we greet the kind smiles we see weekly in this mobile clinic that caters to people who are experiencing homelessness. It is my job to help them obtain housing.

I see my client—a 60-year-old woman who spends most of her days pushing a shopping cart downtown, talking to herself, never asking for change, and attending day services throughout different churches. I've been working with her for a year, making weekly visits during the day and getting to know her, but tonight is her night with street medicine.

From what I've gathered from our previous conversations, she was once a schoolteacher. She was married, has two grown children, and loves cats. This is all speculation, as I can barely decipher the conversation. She doesn't know her full name, her birthday, or where she is from. Sometimes, she talks about "the pirates" around the corner who are after her. Sometimes she tells me about her day, and sometimes she is mute, tapping the bricks of the wall as if there is something hidden within. Sometimes she is completely incomprehensible, and sometimes the wrong word starts her talking about "how messed up the government is." I don't think she knows I'm her social worker, but I've talked to her long enough that she smiles when she sees me, and in the rare moments of clarity when she is not completely consumed by psychosis, she half-whispers my name.

When I started outreach in the city of Atlanta, I was given the chance to house individuals if they had mental illness and had been on the streets for more than a year. It was part of a federal grant orchestrated by the city to tackle chronic homelessness. In theory, I would encounter an individual, assess their vulnerability, get a score, and then refer them to the city for permanent supportive housing, with the expectation that higher-scoring individuals would get a callback first. My client had scored the highest number in the assessment, high enough to make her a priority above anyone else in the waiting list. I could've housed her within days, except that to move forward I needed the one thing she had avoided all these years. The one thing that made her a priority above the rest, and paradoxically, also the least likely to obtain: a mental health diagnosis.

From talking to the bar and restaurant owners on the block, I deduced that she had been in the streets for at least five years without psychiatric treatment, even though the city's hospital was only a few blocks away. The whole year prior to street medicine, I had interacted with her mostly trying to convince her to go to a mental health clinic. "I only need a piece of paper signed by a psychiatrist and I can get you a house," I'd say every time. Every time she'd respond with the same "No. I'm OK." Sometimes "Maybe next week." One time she looked at me straight in the eye and said, "My kind don't do well in those places." Finally, one morning, in a rare episode of lucidness, we were able to go to an outpatient clinic, only for her to have her panic in the small waiting room as 10 other people sat around her. She fled out the door before they could even call her name.

She was petrified of anything slightly medical. Even in her deepest delusional state she would speak of hospitals as places similar to prisons, jails, and asylums. She knew psychiatric wards were where patients with psychosis were sent, often through forced hospitalizations, often with the help of police interventions and often accompanied by criminal charges. Whenever the subject of the hospital would come up she would disassociate, become angry, quiet, confused, and sometimes would enter a crying spell. "Please don't take me there. Please don't take me there," she'd murmur, almost as if reliving past trauma.

It was that fear that kept her from getting help, and what drove her to create her own bubble in the three blocks she called home. Those three blocks were her everything, her comfort zone, the only way she knew how to survive. She knew exactly where church groups provided meals and at what time. She knew every nook and cranny to get into whenever it rained. She knew every restaurant owner of the neighborhood who allowed her to use their bathrooms to keep clean. She had a stray cat that visited every day. And she had become accustomed to the familiar faces that walked past her every single day. She had created a bubble where her mental illness was nonexistent, and to step out of it meant to deal with the unfortunate reality of how her being a person with mental illness interacted with the rest of the world.

On the first night of street medicine, I engaged with her in the same way we had for the past year, except now with the full benefit of a medical team behind me. Week after week, we'd come back at the same time, right on her doorstep, cracking jokes, providing some food, and gradually discussing the subject of her mental health. Surprisingly, she never exhibited the same phobia that she had around the subject of hospitals, and doctors, and medicine. That's when we realized that it wasn't that she was afraid of getting clinical help. She was afraid of health care as an institution—an unaccounted history that somehow created a phobia of anything slightly medical. A history easily detected by the fear in her eyes: "Don't take me there. Don't take me there. Don't take me there." It's easy to forget that it wasn't too long ago that the mental health system consisted of unregulated practices that perpetuated abuse of people with mental illness.

In this more casual setting, the psychiatrist gained her friendship, until one night she felt comfortable being evaluated. We obtained a diagnosis for her. She started taking antipsychotic medication, and a month later, during one of my morning visits, she looked at me with a huge smile and said, "I'm ready for housing now."

This client is the common image of people experiencing homelessness and mental illness—service resistant, yet autonomous and resilient enough to survive. The city tried to remove as many barriers as possible in obtaining housing; since 1988, cities and social housing providers nationwide have been implementing Housing First policies, which "connect individuals and families experiencing homelessness to permanent housing without preconditions and barriers to entry, such as sobriety, treatment, or service participation requirements" (U.S. Department of Housing and Urban Development, 2015). However, this only accounts for what happens to individuals after housing. Homelessness is not just a housing issue: it's a symptom of our lack of radically inclusive, available, and patient-centered mental health. The reality is that a lot of the mental health models designed to help those caught in this situation do not work in institutionalized settings. To target people who experience chronic homelessness, we must immerse ourselves into their lives and penetrate that bubble. We are not going to do that sitting behind a desk, inside an office, asking a person with mental illness to maneuver public transportation across town, requiring them to keep an appointment.

It is exactly this gap in care that has given rise to the street medicine movement. By applying the same concepts of Housing First to medical attention, removing barriers, and working within the frameworks of motivational interviewing, harm reduction, and relationship building—techniques and models that emphasize acceptance of the problem while working at the client's pace until they are ready for change—we can create an efficient model for treatment of people with mental illness experiencing chronic homelessness.

Today, after 10 years of homelessness, my client is happily housed, on disability, and was able to continue her treatment in an outpatient clinic after stabilizing. She is now teaching as a volunteer at a church and has reconnected with her children who had been looking for her for a long time.

— Franco Bejarano, MSW, LMSW, is an Atlanta-based social worker, writer, and artist interested in the intersection of mental health and urban spaces.

Reference
U.S. Department of Housing and Urban Development. (2015). Housing First in permanent supportive housing. Retrieved May 24, 2018, from https://www.hudexchange.info/resources/
documents/Housing-First-Permanent-Supportive-Housing-Brief.pdf.