Healthy Minds With Dr. Jeffrey Borenstein

- [Jeff] Welcome to "Healthy Minds."

I'm Dr. Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence.

With help, there is hope.

(gentle music) Today on "Healthy Minds."

- The stereotype of I know an old white male drinking alcohol is very much outdated.

The modern day homeless population consists of veterans, women-led families, racial minorities, and there's many different types of homelessness that are important to be aware of, such as those who are living on the street versus in shelters, or those who are chronic versus transitionally homeless.

And each of those different subtypes are associated with different outcomes.

- That's today on "Healthy Minds."

This program is brought to you in part by the American Psychiatric Association Foundation and the John & Polly Sparks Foundation.

(gentle music continues) Welcome to "Healthy Minds."

I'm Dr. Jeff Borenstein.

Homelessness, we all see people who are homeless out on the streets, but what can be done to help them?

Every night in the United States, over half a million people are homeless.

Today I speak with leading expert Dr. Katherine Koh.

Dr. Koh is an assistant professor of psychiatry at Harvard Medical School and a key member of the Boston Healthcare for Homeless Program.

Katie, thank you for joining us today.

- Thank you so much, Jeff.

It's a pleasure to be here.

- I wanna jump right in and start off by talking about the scope of homelessness.

How large of a problem, how many people are affected by this each day?

- Absolutely.

So estimates suggest that about 560,000 homeless individuals are present on any given night.

And it's important to note that within that population, there's tremendous heterogeneity.

We tend to think of the homeless population as a kind of a homogeneous population, but the stereotype of I know an old white male drinking alcohol is very much outdated.

The modern day homeless population consists of veterans, woman-led families, racial minorities, and there's many different types of homelessness that are important to be aware of, such as those who are living on the street versus in shelters, or those who are chronic versus transitionally homeless.

And each of those different subtypes are associated with different outcomes.

- Good.

And I'm gonna want to get into some of those differences, but I'd like to start by asking you to describe the program that you are involved in which treats and helps homeless people in Boston.

- Sure.

So I feel tremendously fortunate to work for Boston Healthcare for the Homeless Program.

It's a federally qualified health center that provides care to people experiencing homelessness in 45 different clinical sites throughout Boston.

So it's a very unique model of care in that the idea is to bring care to people who may not be receiving it otherwise, because homeless individuals have been through often unimaginable trauma, oftentimes they're hesitant to seek care, have difficulty in interacting with the healthcare system, and oftentimes people struggle with mental illness that limits their insight and are not proactively seeking care.

So the idea of organizations such as Boston Healthcare for the Homeless Program is to proactively bring care to these individuals in places where they already are.

So for instance, there are a clinical sites embedded in shelters in Boston, and also we have a street team, which I feel privileged to be a part of, where we go out on the street and bring care to where people are literally in emotionally on park benches, alleyways, and under bridges, and try and walk our long journey with them to ultimately bring them to care and to a better life.

- How are you able to engage people who are living under such difficult circumstances?

- It's a wonderful question, and it's such a key part of what I do.

So much of what we do is about building trust and building relationships with people over time.

One of the many things I love about this work is that there's such a range of what you see on the street and so many different stories and experiences that you have in interacting with people.

So, so much is about understanding what moves and motivates people at the time that you meet them, which can sometimes mean just respecting their space.

There are people who often we meet and they initially don't wanna engage and we respect that, but we keep them on our radar.

We don't forget about them, and we try and build relationships with them over time.

And there are other people who are very forthcoming and want to tell you all about their circumstance and life.

And for those people, we try and figure out what their needs are, connect them to care, and ultimately, gets into to a place where they're seeing us for continuity, and ultimately, move them into housing and a better life.

- And you're not working alone, you're working as a part of an interdisciplinary team.

Could you describe a little bit about the other people on the team that you work with?

- Yes, and that is something I also love about the work and that I think is a key part of our model is that it's very interdisciplinary.

So in addition to the two psychiatrists on the team, myself and our senior psychiatrist, Dr. Eileen Riley, we also have primary care physicians, we have case managers, we have a nurse, we have a recovery coach who experienced homelessness 10 years himself and multiple mental illnesses and has completely rebuilt his life.

He's one of the most inspiring people I've ever had the privilege of working with and has this gift of connecting with our patients in a way that myself, without that lived experience, never could to the same extent.

And so having that interdisciplinary care, I think is so effective, in that oftentimes, the initial connection with the patients on the street are made with someone like our recovery coach, Mike, or with our case managers.

Because oftentimes, people on the street have their most immediate priority as something related to case management, like finding food or shelter, and not so much mental health care, which is very understandable given the competing needs people struggle with on any given day.

And so building connections with our case managers is oftentimes how people initially engage.

And then they're more likely to follow up with me if they are recommended by our case manager who they already trust.

And we also have a clinic based at Mass General Hospital for people who live on the street.

And so once we get them to come to clinic, we have this open door model where I literally try and keep my door open between patients so that, say, a patient is coming from a visit with our recovery coach or case manager, they're much more likely to be willing to walk into my office if my door is open.

And Becky, our case manager, says, "Hey, do you wanna see Dr. Koh today?"

And and I feel so grateful to have the opportunity to work as part of such a interdisciplinary team.

- And tell us about some of the people who are coming as patients for psychiatric care.

What types of psychiatric diagnoses are you seeing?

- Such a wonderful question.

I'm so glad you asked that.

So evidence suggests that 76% of the homeless population has a mental illness or substance use disorder, and I think that is a staggering number.

I would argue that few populations bear a greater psychiatric burden, and yet the resources and attention are nowhere near where they should be to meet that need.

And so I think it's important to emphasize that I see a wide range of psychiatric illnesses.

I think the connection between psychotic disorders and serious mental illness and homelessness is well known.

And while that is certainly true, and I do see a lot of people with schizophrenia and schizophrenia-related disorders on the street, I also see people who struggle with depressive disorders, with bipolar disorder, with anxiety disorders, and importantly, trauma-based disorders.

I think the extent of trauma that I see affecting my patients is so striking.

People have endured unimaginable trauma starting from their early life, and also, importantly, when they're homeless.

I think homelessness in itself is a trauma, and so many people endure such difficult circumstances while they're homeless that leads to PTSD and complex PTSD for people who have endured trauma throughout their lives.

And so a big part of what I treat is actually related to trauma in addition to a whole constellation of psychiatric illness.

- So your treatment may include medication and also talk therapy for the people- - [Katherine] Absolutely.

- That you're helping.

- Yes, absolutely.

And because so much of what I see is the sequela of trauma, I feel like therapy and support and walking the long walk making people feel heard and seen and understood is the most important thing I can do.

I do provide psychiatric medication and think it's important to provide thoughtful, high-quality psychopharmacologic care to this population, just as you would at any other population.

And at the same time, I often feel that no pill I give is enough to take the pain away from what people have experienced or are currently experiencing.

So a key part of the work that I do is therapeutic and connecting with people and valuing them as human beings.

- When you and the team are successful in helping somebody transition into a home, what are the steps?

How does that happen that you get somebody able to really have a place to live, as we all should have?

- Such a wonderful and important question.

Well, the first thing I'll highlight is it can be a long journey.

We think on the order of not only days to months, but even years sometimes.

We have a patient, for instance, who we've been seeing on the streets since 2015, inviting him to come to our clinic.

And for years, he wasn't interested in engaging with our team.

But as I said, we try and respect those people's wishes, but also keep them on our radar and wait for a moment where they might give a little more eye contact or a wave or smile or half a smile, and use those moments to try and reconnect.

And so one such patient finally came into our clinic in 2022, so after seven years of invitations to our clinic, he was finally ready to engage and take that step forward in his life.

And I'm happy to report, he's currently sober, he's on a pathway to housing.

And I think that's important to keep in mind, kind of the longitudinal nature of what we do in order to get people into housing and how long it can take, but that will always hang in there with people and never give up until we get them to that outcome.

And a big part of it is connecting with our case management team who are phenomenal and are very well versed in the different resources within Boston.

One of the reasons I think it can be so hard for homeless individuals to get housed is because the housing world is so complex and the process for getting housing can be so confusing and complicated for anyone, let alone people who are struggling with mental illness and the trauma of being on the street.

And so walking people through that process and trying to make sure there's an address to send the forms to, making sure the forms are filled out correctly, all of those processes are things that we try and pay attention to in order to get people on the pathway, and ultimately, into housing.

- In your experience, obviously, some people stay in shelters, some people stay out on the streets, both a homeless.

What brings somebody to decide to stay out on the streets versus staying in a shelter?

- Yes, that's a great question and an important distinction to be aware of.

There's a growing body of evidence that people who live on the street as opposed to in shelters have even worse outcomes in terms of physical health, mental health, and healthcare spending and utilization in addition to premature mortality.

And there are many reasons that people choose to stay on the streets as opposed to in shelters, but it's not as if they want to stay on the street, it's more that they feel forced to do so because it's a better alternative to them than the shelters.

I hear from many of my patients that shelters are dirty and loud, very brutal environments, where people often get into fights, they get stolen from, they feel dehumanized sleeping with hundreds of other people around them.

And I think those factors, in addition to people struggling with mental illness and PTSD or delusions, you can understand why sleeping on the street can seem like a better alternative, but at the same time, sleeping on the street can lead to even worse outcomes, such as being exposed to the elements and the rough weather and people having more injuries.

And studies actually suggest that people who live on the street have a four times greater mortality rate than those who stay in shelters.

So it is a key distinction to be aware of and why our team specifically focuses on those who stay on the street.

- Right, with a goal, obviously, to get permanent housing, but even transition to a shelter for safety, if possible, in that process.

- Yes, exactly.

- You are in Boston.

We know Boston has cold winters.

What do you do on a very cold night?

- That's a wonderful question.

We have a team called the Task Force within Boston that includes healthcare providers from our organization, Boston Healthcare for the Homeless Program, but also people from the Department of Mental Health, from the Boston Police Department, from various homeless service organizations throughout the city.

And there's an annual winter planning meeting every year when we talk about the highest risk folks and make a plan for how to monitor those individuals in the cold weather.

And then also we work with various city and state agencies to make sure that there is enough shelter space and that there are alternatives to shelters when needed.

So for instance, sometimes bus stations or train stations will stay open in the particularly cold weather if there's an exceptionally cold night as a way to make sure people have a place to go.

And it can be difficult.

There are still people who sometimes, for various reasons, choose not to go into shelters.

And then we have to make clinical decisions about whether we wanna engage with them personally to talk to them about the value of going into shelter or also involuntary commitment, Section 12 is what we call it in Massachusetts, is an option we have used in the past.

It's a last resort option, but sometimes if we think people are at risk for life-threatening injury or death because of the cold, we have used that option as well.

- So imminent danger would be- - Yeah.

- A reason for involuntary admission to a psychiatric unit?

- Yes.

Correct.

And we can talk more about that.

It's certainly a very controversial issue, which we don't take lightly, but it is an option that, unfortunately, we have felt we have needed to use in the past in order to protect our patients' lives.

- I'm curious, working with people who sometimes may need that, what's your sense of sort of the balance of protecting somebody's safety versus perhaps their right to choose whether or not they are admitted to a hospital?

- Uh-huh.

It is something that I think about all the time.

It is one of the hardest parts of what I do.

And I think thinking of it as a last resort option is how I was trained and how I still tend to think about the decision to involuntarily commit someone because to take away somebody's autonomy and dignity is, of course, an extremely weighty decision.

At the same time, I've come to think, is it really autonomy if somebody's thought process is clouded by a disorder that prevents them from making rational decisions?

And so often, we see people who are suffering on the street for years and who are on the borderline of needing involuntary commitment.

And those are the patients who really plague us in terms of trying to decide how to proceed and whether or not to involuntarily commit them.

So one story that particularly stands out in my mind that I think about regularly from my mentor, Dr. Jim O'Connell, who's the founder and president of Boston Healthcare for the Homeless Program, really shows how complex this issue is.

So there was one patient he met out on the street and he thought about whether or not he wanted to section her for years.

She was right on the line and he decided not to out of respect for her autonomy and civil liberty.

And then one day, she ended up worsening in terms of her psychotic symptoms and was sectioned by the police.

She ended up going to a hospital.

One thing led to another, she did really well, was started on medications, ended up in a group home, and started working and rebuilt her life.

And so he saw her several years later at an event and she looked at him and she recognized him, and she said, "How dare you?

You left me out on the street for 10 years."

And I think that really speaks to how complex this issue is.

Here's Dr. O'Connell trying to respect her autonomy by not sectioning her, but really what she was saying was, had she been in her right state of mind, she would've wanted him to act sooner.

So I think that's a powerful illustration of how complex this is and how carefully we need to weigh the pros and cons of sectioning because sometimes it really is what people need to get the care that they deserve and to rebuild their life.

- Yeah, I think it's a very important point that you're making.

If we were walking down the street and saw somebody having a seizure or having a heart attack, and even if they said, "Leave me be, leave me be," we would call an ambulance and get them help.

And there is some gray line that perhaps somebody with a psychiatric illness may not want help, but that lack of desire for help is really a symptom of their illness.

And with treatment, they would then get the help that they need, as you just described.

- Exactly.

I think that's well put.

- You're obviously so very passionate about this.

I'd like you to tell us a little bit about how you as a psychiatrist became involved in helping people who are homeless.

- Yes.

I absolutely, love the question because it's one I've given a lot of thought to.

And one of the things I love about psychiatry is it's a field that really encourages self-understanding to best relate to your patients.

And so I'm actually very grateful to my residency program because I feel like during residency, I had wonderful supervision where I really explored what draws me to this work.

And the best answer I can give is I essentially grew up in the opposite of homelessness.

I grew up in Andover, Massachusetts, which is a lovely suburb of Boston, and had essentially everything a child could want in life, good health, a wonderful education, and most importantly, two loving and extraordinary parents.

I think there's so many ways to be privileged in life, but I think a way that's not thought about enough or talked about enough is really just having loving role models in your life.

And every day as a street psychiatrist, I see how much childhood trauma and neglect ravages people's lives and minds until old age.

I still have patients in their 70s talking about the trauma they experienced as a child.

And so I feel so profoundly fortunate to have been raised with the parents and family that I was, where the home was really a place of refuge and stability, as I wish it could be for every child in this world.

And so from there, I went off to college, and homelessness really wasn't something I had thought about or encountered coming from the background that I did, but I went to Harvard for undergraduate.

And for anyone who's spent time there, there's actually a striking prevalence of homeless people in Harvard Square.

And so the juxtaposition of seeing people living in abject poverty, in the shadows of the richest university in the world really bothered me and also piqued my curiosity.

And so I still distinctly remember the first time I ever talked to a homeless person, just being struck by how normal the conversation was.

And I think I had these misconceptions that these individuals would be difficult to connect with or on a different wavelength.

But I was so struck by how, despite being from different worlds, the connection was easy.

And we talked about the weather, the Boston Red Sox, and we went on our way.

And that moment really shattered so many misconceptions I had about people experiencing homelessness and really made me realize these individuals are just like me and only happened to have been dealt a completely different set of cards in life.

And had I not been so lucky to have been born into the family that I was born into, I could easily be in their shoes.

And I feel like that's a fundamental animating principle of my work to this day, to strive to give my patients the healthy and supportive relationships that my parents gave me, that they were denied through no fault of their own.

- Your passion clearly comes across as you speak about it, and I'm sure it comes across to the patients that you meet.

- Thank you.

I truly feel so fortunate to be involved in this work.

It really feels like a calling to me.

And I am in awe of my patients.

I think they have been through unimaginable trauma and still have this breathtaking resilience and ability to walk forward in life and still get up every day and strive to be kind and have goals and wanna work towards a better life.

And I have the deepest admiration for that.

And it's what keeps me going, despite the many challenges of the work.

- I think you make a good point in terms of the resilience.

I couldn't imagine myself being homeless and surviving one night like that.

And here are people who are doing that day in and day out.

Speak about the resilience in the people that you are seeing.

- Yes, it moves me and it motivates me every day.

As mentioned, the stories of childhood trauma and neglect that people share with me never cease to blow my mind, the extent and depth of trauma that people have experienced, including one patient who on separate occasions saw both his parents pass away in front of his eyes, patients who were left in dog cages as a way of punishment, people who were regularly physically or sexually abused.

I always ask my patients when I get to know them to describe their upbringing, and I would say 99% have these deeply painful stories that they share about the way that they grew up.

But I think that's something that's so underappreciated about people experiencing homelessness.

It's not that these people are lazy or didn't work hard enough, but it's that they were not given the opportunity in life to develop in the way that people who come from privilege are able to.

And that profoundly affects their ability to relate to other people, their ability to relate or regulate their mood, their ability to navigate this world.

And so the resilience is in seeing how people, despite that trauma, still come to appointments, that they still want to even engage and give me a chance on the street, that they even are considering trusting this psychiatrist that they never met to help walk with them on the journey.

I find so much beauty in that, and it's something that I'm so grateful my patients are willing to take a chance on so that we can together move to a better place and get them to a better life.

- Well, I could see from speaking to you why patients would be engaged and feel safe and comfortable with you.

- Thank you.

(gentle music) - Please join us for the next episode of "Healthy Minds" as I continue my conversation with Dr. Koh.

(gentle music continues) Do not suffer in silence.

With help, there is hope.

(gentle music) This program is brought to you in part by the American Psychiatric Association Foundation and the John & Polly Sparks Foundation.

(gentle music continues) (gentle music continues) (gentle music continues) (gentle music fades)