How Does a Psychiatrist for People Who Are Homeless Do Her Job?

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S1: This ad free podcast is part of your slate plus membership.

S2: You’re listening to working show about what people do all day. I’m your host. Jordan Weisman. And I’m back this week with another episode in our series about those who work in homelessness services helping society’s most vulnerable.

S3: Last week, we learned a little bit about the world of street medicine. This week, we’re going to be talking to a psychiatrist who works with people experiencing homelessness. Specifically, I spoke with Joanna Freed, who is a psychiatrist at Geniune in Medical Care. I talked to her about what it’s like to work with patients who often have severe mental illnesses or addiction issues, who also live in just the most unstable possible circumstances. And you know how she has to be creative in how she tries to think about treatment and helping these people get through the crazy bureaucracy has required to find your way back into housing.

S4: Once you’ve ended up homeless, if you have not listened to the second episode in the series about social workers of the street outreach team, I recommend you go do that, because in that episode we talk a little bit about how the housing process works, what goes into it, what a housing pack it is. And the psychiatrist said Geniune also play a really important role there.

S3: It’s all sort of integrated. I think it helps you to kind of understand the system. If you listen to the two together, you have listen to that episode. I hope you enjoy this one.

S4: What’s her name and what do you do?

S5: My name is Joanna Freed and I am a psychiatrist for people who are experiencing homelessness. And so I have a couple of roles. I work for an organization called Geniune Medical Care, which provides psychiatric and primary care services for people who are homeless and formerly homeless. And my particular gig within that is that I’m the medical director of the Manhattan Outreach Consortium, which is the street outreach teams that work with people in Manhattan who are sleeping on the street.

S6: And so you’re seeing patients as well as organizing or how does what exactly is your role in the scheme of things?

S7: Yeah. So I have a clinical role. So two and a half days a week, I spend seeing patients working with clients of the outreach teams. I don’t really consider them patients until they’re like agreeing to be in treatment with me. But I do see all the clients of the outreach team because in order to get a housing package together, New York City, you need to have an evaluation from a psychiatrist. So that’s my role on the outreach teams. And then I provide ongoing treatment if somebody is interested or willing.

S8: So how many people are you seeing in the course of a week?

S9: Oh, that’s a really good question. It can vary pretty radically when people show up. It can be you know, it’s very low volume because takes a lot more time than sort of like a traditional sitting in a clinic, seeing patient after patient. So in a typical day, if everybody shows up, I might see like two or three people who are brand new to me for evaluation. And then I might see two or three people for ongoing follow up and treatment. That would be like a typical day. And on any given day, there’s like, you know, 30 percent of the people won’t show up for their scheduled appointments.

S8: That’s that’s this sort of uncertainty. I guess that’s part of the job. I I’m really interested in the what you just said about people agreeing to treatment and how they’re not a patient until that moment. But I want to kind of roll back to the beginning, which is how do you end up in this particular line of work? What made you decide to go into being a psychiatric professional for the homeless?

S9: Oh, my goodness. So tell me your origin story. How you. I’ll tell you my whole life story. I. So I was like a sort of nontraditional. I’m wiggling my fingers in quotes. Medical student in that I didn’t go to college thinking I was going to be a doctor. And so I didn’t do anything pre-med. So I graduated college. I had like sort of this vague idea that I wanted to participate in social justice in some form. And so sort of flaked around and tried a bunch of different stuff and then had a settlement. What did you try? Oh, my gosh. I moved to San Francisco and worked for like an educational nonprofit. I came back to New York and like temped at a big, like, securities firm and then like, took a year off and traveled in Southeast Asia and then came back. And still, I know I do what I was doing. And then finally, I had this medical event myself where I had a ruptured thoracic disc in my spine. And it was sort of a very acute event and ended up with like this, you know, needing to be rushed to the hospital and have emergency surgery. And something about that event kind of like triggered like, oh, wow, like look what’s happening. You know, I’m in the most vulnerable, sort of helpless, very scared place ever. And there are these amazing people around me who are sort of like putting me back together and taking care of me. And I mean, I was a little overdetermined because both of my parents are physicians. So I’m not going to say it came out of nowhere.

S6: It’s like, you know, they say like genes have to be sort of triggered.

S9: It was a little epigenetic moment. Yeah, exactly. So. Yeah. And so from that point on where I sort of did Postbank program and the pre-med classes and then I went to medical school and in medical school, it sort of came down like, you know, in medical school, you try everything, you sort of rotate through every possible service. And it really came down to me for like to like psychiatry was by far the most interesting thing that I did. You know, there were similarities in terms of people’s the presentation of people’s illnesses, but every presentation was still so sort of like independent and unique and required like a different kind of problem-solving. Yeah. And so I really like psychiatry. And so I decided to do my residency. And so I did a residency at NYU and NYU. You work at Bellevue, you work at the V.A. You work in like the public hospital system in a really significant way. And it was like very clear to me that that’s what I wanted to do. I want to work with severely mentally ill people. I wanted to work with people who were sort of really disenfranchised. And my last year of residency, I applied to do the public psychiatry fellowship at Columbia, which is like the greatest gig in psychiatry you can have because you have a year after residency where you have like a real job in the public psychiatry world. But you have two days a week where you are in class with these other like nine other really amazing new psychiatrists with a faculty of people who are sort of, you know, at the top of the public psychiatry field and they bring in all these like amazing speakers. And so during that year, I had my two days a week where I was like in the ivory. Power. And then I had three days a week where I was gonna have to find a job in public psychiatry. Yeah. And my friend Christina was like, oh, you have to meet my supervisor van. He runs this thing called PPO each. And it’s amazing. And, you know, it really like each other. So Van took us out to Korean food for lunch and I was sold. I was like, I wanna work for this person. And that was. And that’s how you made your way. And that was it. So this was your first real job, essentially? Yeah. How many hours goes was.

S8: Ten. Ten years ago. Yeah. Can I ask, what was it or what is it about working with the severely mentally ill people in that condition that was appealing to you or draw you?

S7: I mean, I think that it’s often people who are sort of suffering the most acutely, which is not to say that people with sort of more like less severe mental illness don’t suffer, but it’s often people who are suffering the most and who have the least access to treatment and to help. And also, so many of our tools are kind of blunt instruments. And so you have to be pretty creative in terms of thinking about how to treat somebody with schizophrenia or really severe bipolar disorder. And what you mean by blunt instruments like our medications work. But, you know, they work only some percentage of the time and they all carry a pretty heavy side effect burden. And, you know, most of the data shows that like some combination of treatments is usually more effective than one. And so, you know, you’re not just kind of like I’m going to give you an anti-hypertensive until your blood pressure is normal. You’re like, I’m giving it a psychotic. But maybe we should also, like, think about some talk therapy or maybe having a job, maybe supported employment would be something that would help. And with people that I work with now, you know, housing is very much part of sort of the treatment plan for everybody because, you know, it’s ridiculous to treat someone’s schizophrenia if they’re sleeping on the sidewalk. I mean, it’s not ridiculous to treat it, but it’s there. There is no complete treatment for schizophrenia if somebody is homeless.

S8: I feel like that actually kind of brings us back to that point. I paused on before, which is how someone actually becomes your patient. So when you first see someone, how do they. You said the outreach team kind of brings them to you or you go to them. How do you first encounter someone who could become a patient?

S5: Yeah. So I I’m very like integrated in this team. Yeah, right. And so the team has the people on their caseload are people who they’re hoping to put on their caseload and they’ll involve me at sort of some point along that process. And sometimes it’s early on where it’s like, you know, we are having trouble engaging this person and they’re ambivalent about whether they would work with us or not. So like maybe meeting with you would also sort of like be another way in. More often what happens is, you know, the teams are definitely are pros at engagement. And like they I really I learn a lot from from their approach. And so more often what happens is they will be like this person’s on our caseload now and we’re working on a housing packet and so we’re bringing them to you for psychiatric evaluation. And the reason for that is because there is supportive housing in New York City. And a lot of people who are street homeless are street homeless because they either have serious health problems, serious mental health problems, substance use disorders, usually some combination of the above. And so people are qualified for various kinds of housing based on what they’re living with.

S8: That’s interesting. Can you maybe elaborate on that a little? But how does the mental health condition they have dictate what kind of housing they can get?

S5: So people who are considered to have serious mental illness are eligible for supportive housing in this particular category. And so, you know, the AMH, the New York state definition of what serious mental illness means is, you know, a mental illness that impairs your functioning in several domains. In my mind, if you don’t have housing and it’s in some part due to your mental illness, then that’s, you know, enough to sort of say this person is significantly disabled.

S6: And when you say supportive housing, how does that what exactly does that mean?

S5: Like what what is supportive housing versus regular housing or supportive housing is housing in New York City that was built under an agreement called the New York New York agreement. There is no sort of standardized definition of what supportive housing is exactly looks like. But basically what it is, it is housing with services attached to it. And whether those services are like you or you live in a building of supportive housing units and there’s case management and medical services onsite, or whether that’s you’re in an independent department, you know, in a building like a general rental building and the services come to you. But it’s it’s units that are set aside and that are subsidized. I say city in the state.

S6: And so in order to qualify for that, they have to have a medical record and a mental health record. And you’re a part of figuring out exactly what their condition is and whether is there. Do you feel pressure at all? I mean, like when you’ve got a client coming through and your determination about their mental health, that has a big impact on where they end up living. I mean, is that in the back of your mind ever like. Okay. Like, if you’re out dealing with an edge case or you’re thinking about a diagnosis like how this is an impact to their future?

S7: Yeah, it’s it’s a real it’s a really good question. And. Yeah. I mean, it’s true, like, you know, the it would be great if everybody could qualify for, you know, affordable, safe, supportive housing because, you know, most people could use a little extra help in some area, but there’s an incredibly limited supply. And so. Yeah. But there there is you know, I wouldn’t say like the teams pressure me to diagnose people so that we can fit them into a certain housing stream. But I will say that, yeah, I’m like very aware of sort of like how my evaluation is going to kind of play into their housing prospects. And I’ve been doing this long enough that I sort of like have some understanding of the housing system. And so I know what might be a good fit for somebody. And I also know, like, okay. Like, you know, I’m not clear what is causing this person’s difficulty or I’m not sure whether this person meets criteria for for mental illness. But I can think of like a few things that we could do to sort of help clarify it or, you know, maybe we can think you’d like this. Know the team is going to think of an alternative housing stream, like maybe we’ll be able to get this person a voucher. So it’s not like unless I diagnose somebody, they’re not going to get housed. But it certainly is. Certainly is in my mind when I’m meeting with somebody. And, you know, it speaks to sort of like it also speaks to like I don’t want to participate in a system that’s like pathologizing people’s very normal responses to very abnormal circumstances. Right.

S6: So that’s interesting. Yeah. Because these people are under extreme stress to begin with. And you have to figure out how much as a mental illness versus what a normal sane person would do in a crazy situation.

S7: Exactly. And a lot of, you know, the vast majority of people we meet have experienced like a tremendous amount of unspeakable trauma, whether growing up or whether during incarceration or whether the course of being homeless like. And, you know, the impact that trauma has on sort of on your brain is is substantial and far reaching. And so, you know, sometimes something can look very much like schizophrenia or bipolar disorder. And actually what it is, is sort of like what has been an adaptive response to trauma in somebodies life, but it’s no longer adaptive when they’re trying to sort of work within the system.

S6: Coming back to when you’re meeting folks for the first time or you’re kind of assessing them, are you are you going up to them ever or you kind of joining the average team or are they coming to you?

S5: For the most part, they they come to me and the office that I work in is like a really nice office space. And people come in and we can like make them a cup of coffee and it feels professional. And so I really kind of prefer to offer that to people if they’re willing to do that. But a lot of times people aren’t ready to do that or aren’t willing to do that. And so I’ll go out in the field. The first housing evaluation I ever did was in Marcus Garvey Park, either Marcus Garvey or Morningside Park. And it was with this older man who had been living in a cave in the park for two decades now. Yeah. And had finally agreed to talk to the outreach team and meet with them. And so they brought me out and he and I sat on a park bench and I was like, oh, this is my dream job. I’m really excited to be doing this. And. And so, yeah, if we if we need to go out, we’ll go out.

S6: How did that conversation. And did two guys get him a housing package or how did it get at hand?

S5: Yeah, he he got a housing packet. He got housed. I mean, so what we do is we like the outreach teams, move somebody inside very, very quickly. Yeah. And we have we have to a shelter or something along those lines with places that are sort of outside the traditional shelter system. Because if somebody is chronically street homeless, they’ve already made it very clear that they’re not going to the shelter system. Right. That’s why they’re outside. Because in New York, you have a right to shelter. Anybody who wants to be staying in a shelter is staying in a shelter. So people who are outside like the city very wisely recognize like that. These are not people who are gonna be able to sort of redirect into the shelter system. So we have like safe havens, transitional beds. We have a lack of beds at the YMCA. And so we can get somebody inside like, you know, within a few days of getting them on caseload. Yeah. And then from there, work on permanent housing.

S8: You’re talking to a guy who’s who’s been living in a cave for 20 years. I mean, that is as extreme as is. You’re gonna get, I imagine. I know you can’t talk about that patient specifically, but I mean, how do you in an extreme case like that, how do you begin a conversation where what are you talking to someone know generally about how are you trying to feel out there, their situation?

S7: I usually open up the conversation by being very clear about what our meeting is about. And that I’m a psychiatrist and that this is sort of because you’re working with the team on getting a housing package together. You know, that’s like my role is to create one piece of this stuff that goes into your housing packet. So I’m like very clear about sort of like the frame that we’re working in. And a lot of times people have had like really negative experiences was the mental health system. And so I sort of try to be clear that like, you know, the. This meeting isn’t sort like treat you against your will or send you to the hospital, the point of the meeting is to sort of work on your housing. And then I usually start out by sort of asking people to tell me a little bit of the story of, you know, how they ended up without housing or what there are, you know, whether they ever had housing and what that looked like. That’s usually sort of the way we start the conversation.

S10: If somebody is really sort of, you know, ambivalent about talking to me at all or really kind of not interested in talking to me at all, I kind of try whatever it takes. You know, I’ll ask him about, you know, sports or the cave, you know, his shoes or, I don’t know, just make conversation.

S6: Yeah. It’s just I guess you’re ah. You’re just trying to establish a relationship at that point. Yeah. I mean, are there tests that you’re eventually going to do to say, OK. Does this person have it’s a friend or bipolar disorder? I mean, is there a point where you’re saying, okay, I have to go through sort of a rubric or when does that come into play, you know, with some people?

S5: A lot of that is kind of like observational. If somebody is like incredibly disorganized and like, you know, saying things that sound like pretty significantly delusional. You know, I probably won’t go through the checklist of like diagnostic criteria, like. Do you experience splinting of I just wool’s sort of you know, it’ll be a more observationally based diagnosis. But yeah, at some point I usually do kind of with most clients I like will ask that and like, have you ever experienced this? Have you ever experienced, you know, these signs and then a depression or mania or psychosis or anxiety and you know it. So it’s it sort of gets to the heart of like psychiatric diagnosis in that like this is a really different way of doing that than if I were working in a hospital or an emergency room where I have at my disposal the ability to sort of rule out any potential medical contributor to this. Right. I’m generally not able to get blood tests on somebody or head imaging.

S7: I’m generally not able to get like past records or speak to somebody who knows them or speak to a past provider or test them to see if there’s like some substance that might be causing them to sort of appear psychotic. And so it’s a really different process that I learned sort of working in a hospital based system.

S6: It’s just purely observational, I guess. Or are there other. Is there anything else besides just conversation? You have to go on?

S5: No. I mean, sometimes you can get records. Somebody will consent to that. Sometimes we can look up somebodies, you know, past Medicaid, use histories. Sometimes, you know, we do have a street medicine team attached to outreach and they’re amazing. So sometimes we can, you know, work with them to sort of work up a medical rule out. But generally, none of that is going to happen in that first meeting. And I’m usually sort of having that meeting and and writing and evaluation. And I sort of when I do that, like so writing an evaluation like documenting this encounter with somebody is a sort of specialized skill that I think, you know, it’s taken me a decade to kind of.

S8: Yeah. Get well, I was gonna say, how did you know when you were first starting this job? And you’re kind of working with like the most minimal amount of tools possible in the field or with your patients. How did you adjust to that?

S5: I mean, I always was like I always was much more interested in sort of like the actual interaction and hearing somebody’s stories and sort of, you know, thinking about how to characterize what I was seeing than I was in sort of like an academic, like, you know, rigorous approach to like, you know, here’s the world of what can be going on with this person. And I’m going to like figure out exactly, you know, what particular name in the DSM we’re going to call it. So I think it was sort of a good fit for me. I think I could tolerate the uncertainty because I think maybe my overall philosophy about psychiatry is that like it is in many ways a very I feel that’s very about uncertainty and about discovery.

S7: And so I think I think it has worked for me. I was OK with it.

S8: The stereotype about people on the street is that they’re crazy, yadda, yadda. You know, I mean, you’re at all time. What percentage of the people you see would you say really do have a severe, you know, mental illness since you see basically everyone who needs a housing package? I mean, they all come through you at some point.

S7: Well, I’m I only work with two of the teams. There are there are right now eight psychiatric providers. There are four teams just in Manhattan alone.

S8: But I don’t know everybody. You’re on your corner of the beat. Go The View. Yeah. So, yeah, I mean. Well, what would you say? Like ballpark. You know, like how how many really do have a severe mental health problem?

S5: Oh, my goodness. It’s really hard to say. I would say that by far the majority of people have some sort of mental health condition. I would say a very, very high proportion of people have post-traumatic stress disorder or some sort of manifestation of complex trauma. And then I would say, yeah, the majority of people have a mental health diagnosis and or a substance use disorder diagnosis. Yeah, some combination of. It’s pretty unusual that somebody has neither a.

S8: So one of the other is probably going on, and that’s usually both, usually both interesting and so when somebody becomes your patient, is your goal managing those illnesses or is it really getting them into supportive housing and kind of getting them to the next step? Or is it both? What I guess what is your role at that point? Once they’re there, you’re a patient.

S5: I mean, it’s the team’s job to house them. Yeah. So and I’m a member of the team and so I have a role in that. But, you know, at the end of the day, I’m not the one who sort of, you know, calling housing providers or making sure their packet gets to the place where there’s a vacancy. It’s really variable. And the way treatment looks in this setting is really different than like, you know, treatment in clinical settings is like somebody is either coming to you for treatment and in treatment or they are not. Right now in this setting, people kind of like come in and out. You know, there’s people on the outreach teams who I’ve known for many years who, you know, will get locked up and then come back out a few years later and come in and see me for an evaluation and then maybe see me for a couple of sessions and then maybe decide they don’t want to. And so it’s very fluid. And so I sort of think of it as like, you know, these like series of treatment encounters with people. You know, what I’ll say is like if somebody is interested in treatment and I think they’d benefit from treatment or even if they’re not interested if they’re ambivalent about treatment, I’ll say, like, you know, do you wanna come back again? And we can talk some more about what some options might be for treatment for you. And sometimes I’ll try to sort of focus on the thing that maybe seems to be giving them the most distress or the thing that seems to impede their ability to get housed the most. I try to be just kind of like very flexible in that. And so sometimes people will, you know, meet me for an evaluation and then come back like one or two more times and then, you know, be off to do other stuff. And then sometimes, you know, there was there was a guy on one of my outreach teams who I was seeing almost every week for supportive psychotherapy, couple of like brief medication trials. He wasn’t really that interested in medication, but we were meeting for like two years.

S6: How does that happen frequently or is that now? It doesn’t happen frequently. Is it more the kind of to three meetings and that’s it versus the two year patient?

S5: No, I have I have some people on the caseload who I’ve been seeing pretty consistently, like while they have sort of endured the housing process, which can take, you know, take a long time. And I have some people who I’m currently seeing who are permanently housed, but who sort of need the additional level of support. So we hang on to them a little bit longer. And it’s hard for me. Like sometimes the team has to be like, listen, we really need you to sort of like figure out the next step for this person’s treatment. Like because he’s filling up time in your schedule. He’s been permanently house for a year. He can handle going to a clinic. And sometimes I have trouble letting go because, you know, I just I know the sort of public mental health system. And I know that, like, nobody’s gonna have the flexible frame and the amount of time and the sort of ability to tolerate uncertainty that I do. Right. So when I refer somebody to a clinic and they miss three clinic visits in a row, they get a letter from the clinic saying, you know, we’re discharging you from the clinic. If you want to re-engage in treatment here, you have to kind of go through the intake process again.

S6: That’s really interesting. So you have to feel a little bit of concern about someone being ready to go to another provider ready.

S5: And also just like knowing sort of, you know, the state of public mental health in the city, like, you know, I am incredibly privileged that if I want to see somebody for two years every single week for supportive psychotherapy, like I have a job that allows me to be able to do that. A lot of times, if you are a psychiatrist working in a clinic, you have 15 minute appointments all day long. You’re prescribing, they are seeing somebody else for their therapy. And, you know, I understand why people are under those constraints. It’s because the system sucks, but it’s not constraints that I’m under. And so sort of passing somebody along to that system sometimes feels really hard.

S6: It seems like they’re kind of two parts of your job in a way. It’s like you have the housing evaluations, which are you have to do that. That’s like the that’s kind of a core thing that has to get done. And then you have sort of the more flexible treatment aspect of it. Is that like is that a good way to break down your job? Sort of like that? If I if I’m trying to just simplify for listener, what’s a simplified that’s sort of that kind of the two poles of it? Or would you say there’s another aspect?

S11: There’s a couple more aspects. One is sort of like an advocacy piece where even if like somebody is not coming to see me or like my quote unquote patient, but, you know, I am following this client with the team and they are you know, they got rejected from this housing opportunity. And the reason that the housing provider gave is that they lacked insight into their mental illness. And sometimes we might push back against that because lack of insight is actually a symptom of schizophrenia. And so sort of like using that as a reason to not accept somebody who has schizophrenia is actually inappropriate. And so sometimes I’ll sort of get involved on like these systems level things, you know, sort of advocate for people. I also do like a fair amount, like as a psychiatrist for a team, I do a fair amount of like, you know, either informal or formal, like sort of in-service teaching kind of stuff. So the team the teams that I work with are. Great. And like super familiar with kind of mental health diagnoses and working with people and patient centered ways, but sort of giving people more tools to sort of understand mental health issues and understand how to approach them or understand how to sort of help people with harm reduction when they have substance use disorders. So I do a lot of kind of education and training. And then in my sort of leadership administrative role with outreach, I’m sort of involved in kind of some of the more big picture stuff when it comes to the medical and psychiatric care that we provide for outreach.

S6: Are there medications that you if you were in your private practice, you would prescribe, but because someone’s homeless, it might not be able to take them consistently that they’re just not really in your in your toolbox?

S12: Definitely. Yes. Can you give me some examples? Sure. I mean, I had a small private practice for a bunch of years, and I definitely, you know, had more at my disposal. So medications that are that maybe have a street value or more abusable, I might be less likely to prescribe. Interesting. Or kind of Xanax or exactly like benzodiazepines and medications that require blood monitoring, like until somebody is like inside and we’re gonna be able to like, you know, get blood tests, I would be less likely to prescribe.

S6: How much does that limit your toolbox? A fair amount. Yeah. Again, it’s interesting to me because like you said before, wickham’s diagnosis, you have fewer tools. You don’t have all the hospital bells and whistles. Comes treatment. You have to sort of work with a limited palette if you’re tools. And also for follow up at the same time, you have to get people through a fairly difficult system. Yeah, in the worst circumstances, I imagine us to be like a minor miracle when it actually works. All right.

S12: I guess. But I think like going back to what I said earlier, like it sometimes feels like, OK. Like, you know, we have less at our disposal in terms of kind of like, you know, pharmacotherapy or we have less at our disposal in terms of being able to consistently get somebody in for appointments. But we’ve so much more disposable in terms of like flexibility and being able to sort of like honor, you know, how somebody feels comfortable working with us and being creative. And, you know, like, again, like if I were in a clinic where I was seeing somebody for fifteen minutes and writing them a prescription, I feel like I would have so much less at my disposal. Like, okay, yeah, I could prescribe medication that they have to get weekly blood tests for, but I couldn’t sort of talk to them about, you know, their family or I couldn’t sort of like go in the next office and be like, oh, he’s really interested in a job. Can we hook him up with like our employment program or, you know, like it would be I feel like that would be so much more limiting.

S8: How often are you prescribing medication? Pretty often. I mean, that’s tricky, though, because once on that medication that they have to manage it. Right. And you’re only seeing someone you said maybe three times. Often sometimes. Not always. But I mean, how does that work? How do you once you gets on meds, how are you making sure they’re taking them or how they’re progressing if they’re working?

S5: So a lot of it is just kind of like weighing the risks and benefits. So if he takes this anti-psychotic three times a week. Is that better than him not having any treatment at all? And often the calculus on that is like, yeah, I would rather he, you know, be taking this three times a week and be less psychotic those three days because he’ll be able to, you know, not tank his housing interview or he’ll be able to like go get his benefits turned on. So sometimes it’s recognizing that, like, it’s not going to happen perfectly. And being OK with that. Other tools that we have are there are long acting medications that people can take via injection once a month. And so we try to, you know, encourage if people are interested, we try to encourage people to do that because they don’t have to, you know, keep track of a bottle of pills, remember to take them every day. Often people staying on the street, their stuff will get stolen or if they get arrested, their stuff disappears. And so that’s a really sort of nice way of taking away some of the exigencies of what somebody’s dealing with on the street. So we do some long acting injectables. And then often I you know, I’m really privileged to work with an organization that has providers in like every step of the way along the housing process. You know, often somebody will move into a safe haven where there’s another geniune psychiatrist. And I can be like, oh, you’re going to see Megan and she’s going to be able to continue your medications or you’re going to a safe haven where they can, like, help support you in taking your medication into the like du pillboxes with you. Or you can like go down to the office and take your meds and sort of like figuring out the best way to sort of help somebody get the best treatment.

S6: It’s not always just on you, I guess is part of it is there is a network of professionals at the nonprofit who kind of you guys can kind of tag team or work together. Yeah. In the best cases. Yeah. How often are are you prescribing something? And you’re pretty sure it might not work out because their situation is so erratic.

S5: I mean if somebody is interested, if somebody is like and I and it’s often not somebody who’s like I have schizophrenia and I want treatment for it, it’s often like I can’t sleep or like, you know, I keep having panic attacks whenever I try to take the subway. We’re like sort of these targeted things. Yeah. And so a lot of times, you know, I’ll start something like an SSRI that’s like, you know, pretty low risk and that if they don’t show up again, I’m not going to sort of be laying awake worrying about like, you know, what are they going to do about not getting their SSRI?

S6: Next month, I guess. How optimistic are you guys? Is sort of my question is like, are there points where you’re out, you’re kind of doing it, you’re not sure it’s going to work and just kind of you hope?

S5: Yeah, I think I think you have to be that way to practice psychiatry because think you know, as I said earlier, our medications are often pretty blunt tools and are diagnostic practices, often like a gaten, like a little bit blunt. And so I think you have to like have a certain amount of faith and ability to be optimistic.

S6: In the face of that, you’re dealing with treatments that only have a percentage chance of working and then you’re dealing with patients who on top of that have the worst circumstances. You’re layering challenge on top of challenge.

S5: There are a lot of leaps. Yeah. And so I think, you know, the A bill like you mentioned earlier, the ability to do this job is really for me, you know, based in the fact that, like, I am not doing it on my own. If I were like in a private practice doing this, I would have burned out and like gone to work for a pharmaceutical company or insurance company eight years ago. I think having like feeling like I’m very much part of this network of providers and also part of this outreach team is what makes it possible to kind of like tolerate the uncertainty and the disappointment. You know, just how much suffering there is kind of around us all the time.

S8: This is maybe going to be a dumb question, just like me not knowing how the system works. So kind of a naive question, I guess. It’s put that way. But if you encounter someone who’s deeply mentally ill, really in a bad state and possibly danger to themselves, they’re not making any progress. They’re housing. They’re just on the street. Is there anything you can do? I mean, what if you think this person is really in danger to themselves? So they were out around them. What I mean, is there any way you can intervene or what do you do at that point?

S10: So, you know, we really you know, some of like the kind of catchphrases of of this kind of work are being patient centered or client centered and being recovery oriented and being non-coercive and sort of like working in this very flexible frame. But you’re absolutely right that like sometimes these illnesses are so severe or people’s, you know, symptoms get so bad or their substance use is so out of control that they really are unable to care for themselves or they really pose a danger to people around them.

S5: And so in those circumstances, we you know, the psychiatrists who work for and psychiatric providers who work for geniune and the outreach teams have the capability to do a few things. One is, you know, we used 9-1-1. We will call the ambulance if we really think somebody is, you know, a danger. And the other thing is we have something that’s this legal this legal designation that’s part of mental health law where we’re designated to be able to do what’s called an involuntary removal, which is just the worst phrase.

S10: But if somebody with that capacity so it’s either a psychiatric divider or somebody who’s a license, social worker determines that somebody meets the criteria which are, you know, danger to themself, danger to others or inability to care for themselves, you know, appropriately. And that’s because of a severe mental illness. Then weekends are to fill out paperwork and direct E.M.S. to take them to the psychiatric emergency room of our choosing. Yeah. And we really try to sort of be very thoughtful about not using that unless it’s really kind of the last resort. You’re basically hitting the panic button at that point. Exactly. The panic button with a lot of paperwork and like, you know, negotiation and haggling.

S6: How and I know I’m asking you to kind of describe it worst case scenario, but that feels like. I mean, you have to feel a lot of responsibility when you’re making that call. How do you how do you make that decision? What’s the process for deciding? OK. It’s time to really essentially get Skype. I just temporarily committed is the way put present to the emergency room.

S5: Right. I mean, all it by somebody is a trip to the E.R.. Yeah, but but yeah, it’s still, you know, doing something against somebody as well. I mean, I think if if we have sort of given everybody somebody every opportunity to kind of participate in that process and like, you know, so I’m trying to think of sort of like some recent examples. So somebody who is like unable to care for themselves because they’re so psychotic that they are wearing, you know, a t shirt and flip flops in a snowstorm where somebody who we’ve watched sort of, you know, their medical situation and their leg wounds get worse and worse and worse and, you know, offered them opportunities to sort of get it looked at.

S10: Had our street medicine team tried to work with them and they’re just unable to manage it or somebody who’s sort of like threatening, you know, that they’re gonna harm themselves or who we really sort of believe there’s a high risk of them acting on on what they’re saying. Any of those circumstances would be a time when we would. Probably go ahead and do you know, do a 9 5. Is that.

S6: Is there sort of a group of people who get together at the altar and say, yeah, it’s like a conference or is it a call you can make unilaterally?

S5: I mean, it’s much easier if I have sort help. So usually it’s something that we sort of talk about and it’s usually something that we sort of plan out. I mean, if there’s like a really acute situation where somebody is in the office and really agitated and being very threatening, we wouldn’t take the time to sort of do the paperwork and do a removal. We would just call 9-1-1. Is that something that happens? Yeah, less, less often than you would think. But it does happen.

S6: I feel this might be kind of a rude question, but, you know, I think that there is a lot of people who see it almost as dangerous. Right. They’re like, you know, it’s like go. It’s a crazy person again. How often do you see someone who’s actually a danger to others?

S10: Not not often. I mean, I think that there I think that that sort of people who are, quote unquote, like very visibly homeless get sort of tagged as, you know, either dangerous or insane or, you know, for somehow other. But the truth is, I think that I mean, statistically, sort of if you look at people with mental health diagnoses in general, they’re much more likely to be targets of violence than perpetrators of violence themselves. If I think about homeless people, you know, the things that are going on are generally less to do with people’s mental health conditions and more to do with either street life or substance use or money more. You know, that sort of it’s not sort of because if somebody has delusions that they’re getting into violent altercations with people, it’s because somebody owes them money or because, you know, somebody took their stuff for you know, it’s.

S13: Yeah, more the stuff that doesn’t have to do with.

S6: Yeah. That means your patients who you see over a longer period of time. I mean, you do some essentially talk therapy, right or. Yeah. What do you end up talking about with those patients? What comes up?

S12: It’s really variable. So a lot of times it is sort of like the day to day. It’s like tolerating like struggles at the safe haven. It’s sort of like problem-solving about how to sort of not allow your symptoms to, you know, interfere with your ability to do that housing interview. Well, it’s about, you know, working around substance use, like how to sort of decrease substance use and how to kind of think about like what the triggers are and what some ways to sort of use more safely. Ah, it can sort of be like really that kind of like day to day, moment to moment stuff with people who maybe I’m I’m getting to know better and people who are spending more time, you know, doing talk therapy with we might get into stuff like, you know, if it’s something that they want to talk about, we might talk about stuff that happened in their past or we might talk about relationships in their life or sometimes we end up sort of talking about somebodies delusional material. And if it’s something that’s really fixed for them, sometimes will work within like, OK, like, so how do you continue to kind of like move forward towards this goal that you have, whether that’s housing or reconnecting with family or getting a job while you’re sort of dealing with the stress that you experience cause you believe, you know, the FBI is after you or the safe havens putting poison in your food.

S6: How often do you get people who have delusions of that sort of level? Oh, pretty often, yeah. I mean, and you’re having to help them navigate a bureaucracy when they’re terrified of I mean, I guess that’s a pretty classic mental health situation, right? Like you you think like the dark force of like a bureaucracy is out to get or like some kind of Kafkaesque scenario there sounds out to get you. And you’re at the same time having to navigate city services to get a home right.

S12: Where like, you know, maybe it’s benign incompetence that is like causing these things. Or maybe like you said, it’s like the dark forces of evil that’s causing this thing. But the end result is that, you know, it is a really hard system to navigate and it can it does not feel like a benevolent place to be. And most of the time.

S6: So if you’re predisposed to thinking like, you know, having these delusions that just gonna fuel them or that has to be such a right, since a lot of successes is like misattribution.

S12: Right. It’s like you’re not wrong about kind of like the overall scenario. You’re just like, you know, creating a different story about it than what you know, my understanding of the story is, are you pushing back against that?

S8: Are you just trying to like you said, sometimes it’s just helping people deal with the system in spite of what they believe about it?

S12: Exactly. Yeah. I think, you know, in general, sort of pushing back against delusions is not an effective strategy. And for somebody who’s like acutely psychotic or like really sort of has like a formal thought disorder, which is the fancy word for believing something, that’s probably not true. And so, yeah, pushing back against the delusion is not usually effective, but joining with somebody in the things you can join with them about without sort of like, you know, you don’t have to lie and say, I agree with you that there is a chip in your tooth. But, you know, you can sort of say, OK, let’s you know, we can agree to disagree about the chip in your tooth. But the end result is that, like, you feel like you’re really being monitored every moment of the day. And so you feel like you can’t say anything out loud. And so how do we sort of get you to a place where you can answer questions in the housing interview with a chip in your tooth and still be able, ah, with what you think is a chip in your teeth and still be able to sort of like answer those questions adequately so that the housing providers like to give you an apartment that’s problem solving.

S6: It’s OK. We have we’re not going to cure these thoughts. Right. It’s how do we make sure that you can get into a home in spite of them that you don’t self-sabotage accidentally?

S12: Exactly. And I think like that, again, is something like that’s a reason like I’m a really good fit for some of this work, because a lot of times, like, you know, my instinct is to like jump in and and problem solve. And, you know, in the bigger world of psychiatry, that’s not actually often the most effective therapeutic intervention for somebody. Right. Like helping somebody get the tools to solve problems themselves is what ultimately you want to do.

S6: And in your case, you’re at your hands on say, okay, we need to get you to this next step and I’m going to do everything in my power to make sure. Right. How do you. So just to take that problem or someone thinks that everything they say is being monitored and they they don’t want to talk. I mean, like, what would be your go to thing like to solve that problem?

S12: I mean, I’d hope they take a little bit of antipsychotics so that it might take a little bit of the edge off of that that particular delusion. But yeah, they didn’t want to take any antipsychotic then. I think, yeah. We would sort of talk more about like how do you take these strictures that you’re working within and sort of still get what you need to get in order to sort of, you know, meet the goals that you have. And I’m not you know, I don’t mean does sort of like make it sound like it always works. Right? We have people who are really, really, really persistently delusional, who it takes years and years and years and years even just to like, you know, I can think of a particular client on the c.c.’s team who it was years before we could get him to agree to a. Get an I.D. card like years and years and years, like he just he didn’t want to do it. He was kind of working with his own special powers and abilities. He didn’t want to participate in that system. So after, you know, probably like eight or nine years, someone finally like I don’t know if he just, you know, it wore him down enough or somebody sort of had a different approach or what changed for him. And he finally agreed to do that. And he finally ended up. He’s like in an apartment now. But it was many, many years. And none of my interventions were effective with that particular.

S6: How did that feel on your own? I mean, that has to be a little bit maddening.

S12: I don’t know. I think I don’t take it personally. I guess. Yeah. And I also sort of feel like, okay, like this is like I’m not being successful here. And, you know, whether that’s because of my own limitations or because I’m not the right fit for working with this person, whatever it is. But, you know, thank goodness there’s six other people who you know, somebody, and that’s what happened. You know, one of those six other people was the right fit or did have the right approach. Whereas, again, if I were in my private practice, like, you know, I think I would maybe take it a little bit more personally or feel a little bit more lost in that situation.

S6: It’s not all just on you. Is there a point where you ever stop seeing a patient where it’s like, okay, you’re officially handed like you said, you met, you brought up, you kind of recommend them to a clinic or something along those lines, but before that. Is there a point, Rico, to hand them off to a colleague or something or.

S12: Yeah. I mean, you know, I think so. My time is incredibly limited. And I do need to be sort of seeing people for these evaluations so they can get housed. And so, you know, sometimes I’ll be building up this treatment caseload and it’ll get like, okay, we can’t get somebody in to see you for this evaluation, like what’s happening, the treatment caseload. And so, as I said earlier, like, sometimes they’ll need to like, you know, the team will gently need to sort of help me understand that, like some people are probably ready to be seen less often or to move on to a new provider when I can. I love handing them off to people within our system because I can do a really good sign out. I really trust my colleagues. I know they’re gonna be able to sort of like have the same approach and philosophy that I have and the same understanding of where somebody is coming from. So a lot of times we’re able to house people in permanent supportive housing where my colleagues work. So then you have the psychiatrist one day a week who happens to be, you know. Yeah. And Megan. And so that’s the ideal situation in my mind. But then also. Yeah. And, you know, I feel like I’ve slammed like the public mental health system a fair amount and it deserves slamming, but like the actual individual people within it.

S11: And some of the clinics that we work with are wonderful and sort of, you know, there’s some great people working in the systems. And so I sometimes sort of I have my little toolbox of resources for when I really want to make sure somebody lands somewhere good new, you know?

S6: Okay. That psychiatrist at that clinic might be able to handle my patient. Exactly. Yeah. And you pull strings to get them there.

S12: I mean, sometimes. Yeah. Or even just knowing like I can get that person on the phone to really explain this case to them.

S6: I mean like really give them a background and let them know what has worked when you do hands on off to one of your colleagues. Supportive housing or whatnot. Yeah. Do you kind of keep tabs on them ever do you ever go, okay? Oh yeah. I’m doing. Yes. Yeah.

S12: And having been at geniune for ten years, you know, we’re in like every setting possible within this kind of within the housing spectrum. And so I’ve worked in every setting that we have. Like I’ve worked in with street outreach and I’ve also worked in shelters and I’ve also worked in soup kitchens and I’ve also worked in permanent supportive housing. So, you know, there are people like I sort of I know where people are going or where people are maybe coming from. And I also, you know, have people who were my patients in supportive housing for five years who I you know, I left that site. But I still check in with my colleague about like, oh, how so-and-so doing?

S6: Is there something about your job that I haven’t asked you about? Do you think people need to know?

S11: I feel like this is like a little star, either soap boxy or a little like maybe dry and technical. But I think one thing that I have found really challenging. Know we’ve talked a lot about sort of psychiatric illness. And, you know, psychosis and people with really persistent symptoms. And one another part of our job that I think is equally important is treating people substance use disorders.

S6: You brought that up to sort of the other half that you see.

S13: Yeah. I mean, how do you want one of my jobs as in the leadership position is that I we have a quarterly sort of incident review meeting where we talk about like, you know, all the serious incidents that have happened within Manhattan Outridge Consortium, and that includes deaths. And, you know, this this last meeting, we had an unusual number of deaths and many of them were opioid, really opioid use. And it’s something that I think, you know, reflects what’s happening nationwide. Have you been seeing that creeping up over time? Yeah. Yeah.

S11: And, you know, we have we have some tools to sort of either help people use more safely or help people reduce their use or even. Stop using if that’s what they want. But there are so few ways for people to access those tools within their system. And so I feel really good about the fact that we can sort of provide like a low barrier way for people to access them. But I sometimes feel so frustrated by how many barriers there are everywhere else to accessing them. And so like taking a lifesaving medication like Suboxone shouldn’t be that hard. And yet it’s incredibly hard, even like sort of the public. And Suboxone is just Suboxone is a medication that people with opioid use disorder can take to replace the heroin. And it’s a daily medication. It’s a medic. It’s similar to methadone in that it triggers your opioid receptors. It’s different from methadone in that you can get a prescription for it and take it on your own instead of having to go to a program every day.

S6: You said it. It’s extremely difficult for people to get access to it.

S11: It can be. Yeah, because you a doctor needs a special waiver. You have to do a special training and get a special prescription waiver and now to prescribe it as opposed to opioids, which any doctor with a license can prescribe. And so, you know, I recently learned that like within the public hospital system, like a very low proportion of providers are wavered to prescribe even morphine, which is, you know, this lifesaving medication for this epidemic that we’re in. And so that’s been one of my sort of like the things I’ve been thinking about the most recently and one of my real sort of frustrations for a normal psychiatrist.

S6: The goal is to assume it’s either to manage symptoms or I mean, does a psychiatrist ever really cure a patient’s symptoms? How often does that happen? It’s more managing them, right?

S12: I think it depends. I mean, I think, you know what we know about. And again, I think we’re talking right now about like serious mental. Yeah.

S14: What we know about serious mental illness is that there is probably like a much higher rate of recovery than maybe we fully understand. But because we define it certain ways and because we don’t necessarily follow people longitudinally the way that we maybe used to be able to, we don’t necessarily always see those outcomes. You know, I think there’s a fair amount of recovery that goes on. And I think, you know, particularly when you’re talking about somebody with these symptoms, but who has these symptoms in a particular context, which is that they’re sleeping on the street and so constantly in danger and incredibly sleep deprived and having to focus on kind of their immediate needs instead of like anything bigger where they’re constantly getting, you know, their PTSD triggered by being in that circumstance where they’re maybe using substances either to sort of help cope with some of these things or because, you know, they have cravings to use substances, you know, from a chemical imbalance. And when you sort of are able to sort of like help remove somebody from some of that context, I think like I have often been really surprised, like how different somebody looks in a different context. And when I was saying earlier about like how somebody behaves in like a really inhuman, insane scenario does not necessarily kind of define how they’re going to be once they’re in a place that a human being should be.

S6: Well, this is what I was wondering. And you sort of got up as how often do you see someone who has one of your patients actually recover?

S14: So recovery is sort of defined in this like that. There’s this like concept called recovery in psychiatry that is not necessarily about sort of, you know, going from having a lot of symptoms to having no symptoms. But it’s a list, this sort of like process based definition that’s like sort of about somebody getting to a point where they’re, you know, functioning in these various ways that they weren’t able to function previously or where their symptoms are under control to the extent that they, you know, don’t distress them as much.

S11: It’s like a very individualized definition. And so I don’t mean to be mealy mouthed about it. It’s a continuum. And would certainly. Yeah, exactly. It’s a continuum. And so I’ve seen it a lot. You know, I’ve seen people who I was like. Boy, this is like really one of the sickest people I’ve ever seen. And they get inside. They maybe get on Suboxone. So they stop using so much heroin or they get on a medication that helps them drink less. And all of a sudden, they are taking care of themselves and their face looks different. And they can have like these coherent conversations. And it’s it’s very humbling, the sort of like realize that like a lot of this has nothing to do necessarily with us, you know, treating their psychosis. And so much of it has to do with like what this whole team and this whole system is working on, which is like taking them out of this situation, which they are having this particular reaction to.

S13: Thank you so much for coming and chatting. Thank you.

S4: That’s it for this week’s episode of Working, I hope you enjoyed the show, as always, if it did leave us serve you at Apple podcasts or send me an e-mail that working at Slate.com can that is working at Slate dot com shows produced by Jesmyn Molly.

S2: A special thank you to Justin Debride for the ad music. I’m Jordan Weisman. Catch us next week.