Taking the clinic to the streets

Every Thursday, a group of UNC psychiatrists leave campus and head to Franklin Street armed with plastic bags of tiny shampoos and travel toothpaste tubes, washcloths and bars of soap, thick new socks and knit hats.

For the afternoon, the street is a moving clinic of sorts where Annie Kelly, clinical associate professor of psychiatry, and psychiatry residents Anisha Gulati and Alicia Watson are looking for the patients who might not think to look for them. An offered hygiene kit – full of essentials that many take for granted – is not only a kind gesture, but also a conversation piece, a way to open the door to something bigger.

“Many of Franklin Street’s homeless population may have psychiatric needs – a mental illness or a substance use disorder – but no resources with which to treat them: no money for a copay, not even the $4 it takes to fill some psychiatric medicines,” said Kelly. “Many of them remain untreated, or seek care in the emergency room, which isn’t the best place to get them connected to what they need.”

An untreated mental illness is a big barrier to housing, and it can be a vicious cycle to break. The group has teamed up with Matt Ballard from Housing for New Hope, who works out of an office in the basement of the University United Methodist Church. Together, they walk up and down the downtown street, stopping to talk to people they’ve already gotten to know and meeting new people.

This kind of community psychiatry is called assertive engagement, an evidence-based practice that works to get individuals connected or reconnected to needed health-care providers, housing resources and a sense of hope and possibility.

“Sometimes we’ll meet someone and talk for 10 minutes; sometimes they take a hygiene kit, or they won’t,” Kelly said. “After we meet them a couple of times, they might agree to talk about treatment or come to an appointment at the church for a psychiatric assessment. Then, we can figure out what they need.”

Training and treating in the field

The psychiatrist street medicine initiative is an official N.C. AHEC (Area Health Education Centers) Program training site for residents in the medical school’s Department of Psychiatry. It operates under UNC’s Center for Excellence in Community Mental Health and provides unique training for psychiatrists while engaging those who struggle with homelessness and mental illness.

“National statistics tell us that one-third of homeless persons have a major mental illness and up to two-thirds have substance use disorders,” said Kelly. “The rates are very high, and with the shrinking numbers of state hospital beds nationwide, it’s harder and harder to get people psychiatric treatment.”

Sheryl Fleisch, now at Vanderbilt University, founded the program as a psychiatry fellow in 2012 and brought on Kelly, who was completing a community psychiatry fellowship.

They could offer psychiatric assessment and treatment, but weren’t skilled in helping someone get benefits or housing. By linking the program to the University, the group has access to a wider array of options, like Critical Time Intervention, an initiative from the School of Social Work that partners with the center and engages patients in long-term solutions, from housing to independent living skills.

“If we meet someone with a mental illness who needs emergent treatment, sometimes we’ll prescribe medication right there on the street. Then, we’ll try to get them connected to a more enhanced service,” said Kelly.

Misconceptions of the homeless run deep. For many of Watson’s patients, it isn’t something they’ve chosen; many of them haven’t had the opportunities others enjoy. Understanding that is key to providing help.

The patients Watson sees in clinic might be homeless, but in that setting she isn’t exposed to their day-to-day realties.

“It’s hard to deal with homelessness from an inpatient standpoint,” she said. “Coming out and seeing them in their own environment where they live, and meeting them where they are, has shown me what life is like for them.”

Sometimes passersby on Franklin Street can make it even harder, even without meaning to, Gulati said, which creates even more negative experiences for people they don’t know.

“It’s important that if you see or talk to someone who you think is homeless that you don’t do more harm,” she said. “There is already so much suffering.”

An uphill battle

Alcohol dependence, particularly, can create a frustrating housing cycle that Kelly said many misunderstand. New research may turn that around.

“More and more research is showing that it’s not so much a choice to continue drinking. Part of the drive to drink is outside of volitional control, so the medical and psychiatric communities are coming more to understand it as a disease,” Kelly said.

To get someone with alcohol dependence to a place where they can make a different choice requires having a significant period away from alcohol.

“That can take a 28-day stay or longer in a facility, which is expensive and hard to access. It’s very difficult to stop drinking if you aren’t housed,” said Kelly. “It’s hard to do something different if you don’t think you’ll have different results. It’s an uphill battle.”

Kelly and the residents want to build trusting relationships that can give a patient the confidence to make more difficult choices about treatment. Even then, if they can get someone to agree to get help, there isn’t always an available bed.

Small gains count, too, Kelly said. An ongoing conversation, improved symptoms and simply keeping someone out of the emergency room are all positive outcomes.

And sometimes there are incredible outcomes.

“We started working with a man over a year ago, seeing him and talking with him every week. In that time, we’ve also gotten him on medication for psychosis, and he’s in the process of being housed,” Kelly said.

Read more from the University Gazette article by Courtney Mitchell.

April 14, 2014.