Healthy Minds With Dr. Jeffrey Borenstein

- [Dr. Borenstein] 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.

(mellow music) Today on "Healthy Minds."

- It's like if somebody were to collapse or be in need on a plane, or in a restaurant, or a store, clinicians rush to respond, but somehow for people on the street, we become anesthetized and just keep on walking.

- That's today on "Healthy Minds."

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

(mellow music) Welcome to "Healthy Minds."

I'm Dr. Jeff Borenstein.

Today, I continue my conversation with Dr. Katherine Koh about the work that she's doing to help people who are experiencing homelessness.

(mellow music) Katie, thank you for joining us today.

- Thank you so much, Jeff.

It's a pleasure to be here.

- I wanna shift gears a little bit.

In addition to this extraordinary clinical care that you give to people, you're also, and the team, are also involved in research to better understand the circumstances that may bring about homelessness for people and maybe even develop methods of prevention.

I'd like you to speak about that.

- Yes, so I feel so fortunate to be able to conduct research in addition to my clinical work.

I love being a clinician researcher because I feel that my clinical observations can help inform my research and helpfully improve care for patients.

So a lot of my research has been on documenting disparities between the homeless population and the general population, and also creating frameworks for best practices to help this population.

And so for instance, one publication that I will highlight is an article myself and several team members wrote about how to help a homeless person in need on the street.

I think that's something that a lot of people think about but really aren't sure how to proceed because in medical school or medical training, we're not taught at all how to help a person in need on the street.

And it strikes me that as clinicians, in other nonclinical contexts, like if somebody were to collapse, or be in need on a plane, or in a restaurant, or a store, clinicians rush to respond.

But somehow, for people on the street, we become anesthetized and just keep on walking.

And so my colleagues and I created a framework about how to think through what to do when you see a homeless person who might be in medical need on the street.

That was published in JAMA Internal Medicine for anyone who's interested in reading it.

And a colleague and I also recently published an article in JAMA about how to think more comprehensively about policy solutions to addressing homelessness and mental illness.

And the takeaway from the article was that there's no one-size-fits-all policy, but really homelessness is a complex multi-sector problem requiring multi-sector solutions throughout the lifespan.

And one big takeaway from doing this work that I've seen is despite how our goal is to get people into housing, and it's a wonderful thing when we do, unfortunately people still struggle once moving into housing, and it's not as smooth a path forward as we would hope.

And so that's motivated me to think more upstream about prevention of homelessness, as you mentioned, and how do we actually design, and implement, and evaluate interventions to prevent people from becoming homeless in the first place and save them from that suffering that often is hard to get out of once you're in it.

And so my recent research has focused on people transitioning from the Army, and how do we better predict who is likely to become homeless?

And then once we're able to identify those high-risk individuals, how do we target them with a preventive intervention to keep them from falling into homelessness?

And it's fascinating work, and work that I hope to continue to do throughout my career because I really think this idea of preventing homelessness is key and something that's not talked about enough.

- Are the other high-risk groups above and beyond people who've experienced trauma or multiple traumas, what other groups are at higher risk of becoming homeless?

- Yes, absolutely.

So there have been critical transition points that have been identified in the literature where people are more likely to become a homeless.

So in addition to soldiers transitioning from the army, also people leaving jails and prisons, that's a very high-risk time where transitioning to the community, often people aren't given the support that they need and become homeless right away or after a short duration.

Also, children aging out of foster care is another time when people are likely to become homeless, and then people being discharged from hospitals as well.

So if we can better think through rigorous, high-quality interventions to be able to identify those people and then give them the services that they need, I think we could make a meaningful dent in this issue.

And it's something that I'm very passionate about and hope to work on in future years.

- Yeah, clearly.

Prevention is even better than treatment and intervention if you could avoid it in the first place.

- Absolutely.

And we use that paradigm for many diseases, but oftentimes it's not thought about for homelessness.

I think so much of the clinical research and policy focus is on those who are already homeless and housing them, which I think is so important and critical, and that work needs to be continued.

But we also need to shift the perspective upstream and think about all of the events that lead to a person becoming homeless early in life: adverse childhood experiences, racism, poverty, untreated mental illness, the lack of affordable housing.

All of those factors need to be taken into account to truly nip this problem in the bud, in addition to housing those who are already homeless.

- I wanna ask you, there's a perspective that some people have of fear of homeless people, that they may be dangerous or violent, and the reality is that they're probably a greater danger of harm being done to them.

But we see the big headlines when there is a terrible example of a person who may be homeless, may have a mental illness, who then may act out and be violent towards another person.

Could you speak about that a little bit?

- I'm so glad you asked that question because I do think there are so many misconceptions about people experiencing homelessness.

And I do think these rare examples of people who are homeless and act in an agitated or violent way tend to be amplified disproportionately.

And so I will tell you, I've been doing this work for over five years now, and the vast, vast majority of people that I meet on the street are kind, thoughtful, well-meaning individuals who have not, in any way, been violent or inappropriate in their interactions with myself and with the team.

And I think that is something that I wish everybody could see.

And also, that there's a beautiful community that forms on the street as well.

That's something that I think is not often apparent, unless you do this work up close.

But people really care for each other and know each other in the homeless community.

There's friends, romantic relationships, sometimes frenemies and enemies as well.

But the whole range of human relationships you see on the street, and I really think that speaks to how these individuals are just like you and me with just a completely different set of circumstances around them.

And so I am so glad that you highlight that.

Yes, there are instances in which people who live on the street can act in violent ways, but it is very much the minority.

And I would encourage people to, if they feel comfortable to do so, try and have a conversation with somebody on the street.

And I think they'll see that these individuals are just like you and me.

- When somebody who's successfully been able to get a home and move into the home, you continue with them.

- Yes, home visits are a key part of our model and of what we do in our street team.

The idea being that moving into housing can be such a fragile time for people and having that continuity of care with a team that our patients already know and trust can really help facilitate that transition into housing.

And we try and stay with people as long as we can because even years into housing, people can still struggle.

And we really value this principle of continuity of care and hanging in with our patients as long as they'll have us.

And so I think home visits are an incredibly enriching part of what I do.

One of the many things I love about this work is that I really get to see my patients in different contexts.

And so initially, I'll often meet somebody on the street, and the idea is to get them to a place where they're willing to see us for continuity and on a regular basis.

And that can be out in the community.

For instance, I have a patient who doesn't like to come into our clinic and doesn't like to talk on the phone, but he'll meet me in a church basement every two weeks.

And so every two weeks, I'll meet him in this church basement, I prescribe psychiatric medications, and it's a great example of how we can give high-quality care on the street, but we also try to get people to come to our clinic if they're interested, where we can do more comprehensive labs and imaging.

And then ultimately, the goal is to get individuals into housing.

And so being able to see my patients in each of these contexts on the street, in the clinic, and eventually in housing, really helps my understanding of them as a person.

And so often, when I'm doing home visits, I really try and observe both what's there and what's not there.

Pictures of loved ones, artwork on the walls, sometimes you'll see things like cigarette butts or vodka bottles that can give you clinical insight into people's substance use.

There's one patient we thought was adherent to his medications, for instance, and we went to his house, and we found about 70 unopened pill bottles, and realized that he wasn't taking his medications in part due to cognitive challenges that made it difficult for him to organize his medications.

And so we were able to get a visiting nurse established, a VNA, to be able to come and help administer his medication.

So I think that's a powerful example of the value of home visits and how it allows us to get to know and understand our patients, and their worlds, and what they might be struggling with better and help us to direct our clinical care and deepen our understanding of them as human beings.

- So really going into the home gives you a much broader perspective on that person's life, how they're doing, than just meeting in the office or out on the street.

- Absolutely.

And if you think about it kind of just in regular life, I feel like I always understand my friends better when I get to see their apartment, or their home, or their living space.

And so in the same way, I feel like I really can understand my patients that they give us the privilege of them letting us into their home - It sounds to me as if many of the people that you work with actually inspire you, you, to help them and to help others.

I'd like you to talk about that.

- Absolutely, and that's a huge part of why I feel so passionate and motivated by this work is the inspiration that I draw from my patients.

And so one woman who particularly comes to mind that I would love to share about is a woman I met underneath the Zakim Bridge, which is this major bridge in Boston.

My very astute colleague was biking to work one day and saw this tent next to the Charles River in Boston.

And it really speaks to the power of observation and street outreach 'cause had he not been so observant to notice her there, we may not have had the opportunity to connect.

But very shortly thereafter, a team of us went out to try and engage this woman, and we found out that she had been living under the Zakim Bridge for eight years.

We met her on a Monday and she came to our clinic three days later on a Thursday.

And as mentioned, sometimes, it can take people years to be ready to engage, but this woman had the motivation and planning ahead enough to be able to come just a few days later.

And I got to know her over time.

She told me that she had lived in 150 foster homes throughout her life, just to give you a sense of the magnitude of challenges people experiencing homelessness have gone through in their early life.

And yet she still had this beautiful, kind, resilient spirit about her.

Was interested in psychiatric medication.

We eventually started an antipsychotic medication and she was housed within six months.

And I'm glad to report that about two years later now, she remains stably housed, she's working at a gas station 40 hours a week, and she's engaged to be married.

And I think this story just speaks to the beauty of this work, and why we can never lose hope, and why we can never give up on people.

- Yeah, the story really fits in with the closing that I have on every show, which is that with help, there is hope, and you just gave a beautiful example of that.

- Beautiful, thank you.

- Once the person does have housing, what are the obstacles, what are the key challenges that they have at this point to be able to avoid going back to homelessness?

- I'm so glad you asked that question because I think a lot of people, including myself when I first started doing this work, thought and hoped that once my patients got housed, they'd be thrilled, we'd be thrilled, everything would be smooth sailing, and we move on to helping house the next patient.

But unfortunately, the reality is so much more complex and nuanced than that.

And so often people still struggle with their mental health, with their physical health, with a whole range of issues once moving into housing.

And there's actually some preliminary data that suggests overdose risk can even increase when people first move into housing because there's just an illusion of safety that people think that it's safe to use.

But actually, they don't have their community on the street anymore to call 911 if they overdose or to give them Narcan, the opioid reversal agent, if they overdose in their apartment.

And so I think that's something really important that I want to emphasize, is that housing is not just a panacea, and we really have to be thoughtful about our clinical care and approach once people move into housing and tailor that care for each individual.

I think oftentimes, once people are moving into housing, there's kind of this celebration, and we can move on, but actually those people may be the ones most at risk, particularly when they first move in.

And so both the clinical care and the case management care need to be coordinated very thoughtfully.

And I really believe everyone should have an individualized housing plan in the same way there's an individualized psychiatric treatment plan, for instance, in terms of how often a housing case manager will visit a person who's housed and check on them.

I think it really varies for each person, and oftentimes not enough thought is given to what individuals need based on their concerns and what's important to them.

- I wanted to, along those lines, what... We often, all of us, walk by people who are homeless and just sort of keep on going.

What should somebody do if they wanna be helpful?

- Yes.

So I've had many formally homeless individuals and currently homeless individuals tell me that what means more than anything is just having someone look them in the eye, maybe say, "Hello," ask how they are.

Even a nod that can often mean more to people than giving money.

I think sometimes, people feel like they need to give in order to do something meaningful to help, but actually just acknowledging someone's humanity goes so far and is what is most meaningful to a person.

And so I would really encourage people if they feel comfortable to do that.

That's something I strive to do, especially when I'm not working.

So if I'm just kind of going about my day in a city, just at least give people a nod or a, "Hello," and I think it really can lift people's spirits.

- I wanna ask you about a group of people who are homeless that, in many ways, probably pull on our heartstrings more than others, which is families and children.

And I'd like you to speak about people in those circumstances.

- Yes.

I think oftentimes, when we think about homelessness, this is a forgotten population.

We think only about single adults experiencing homelessness, but it's really important to recognize that there are families and children who are homeless.

It's an abomination, I think, that there are homeless children in this country, but it's a reality that we have to face and be aware of.

And studies show that from a very young age, these individuals struggle disproportionately with mental health and substance use issues, have a higher risk of suicide, which is why it's so critically important to be aware of homeless youth.

And so we actually have a dedicated team at Boston Health Care for the Homeless Program who cares for children and families who are homeless because they often do have a unique set of risk factors and needs, requiring thoughtful and individualized treatment.

And so I feel tremendously fortunate to be able to collaborate with colleagues who are particularly focused on this population and have told me so many stories about basic things that we take for granted that we don't even think of.

But for instance, trying to get children their diapers and being able to change them when needed is something that one of my colleagues was telling me her patient struggled with a homeless mother.

And so being a parent is hard under any circumstances, but when you're dealing with homelessness for yourself and for your child, it just becomes a whole nother level of challenge.

And I think that's something that needs to be recognized and addressed as best as we can.

- I wanna ask you about the effect of COVID on the homeless population.

It affected all of us, but what was it like during the worst of COVID, and even now, post the worst of COVID, for the homeless population?

- It's a very interesting question.

We learned a lot during COVID and I think the story's still being written, so to speak, because there's a range of how people responded and different kind of hypotheses as to why that is.

But I'll say one lesson that springs to mind is the value of telehealth for this population.

I think it's kind of counterintuitive or almost an oxymoron to think that telehealth could work for the homeless population, but I actually had quite a bit of success.

There was a period where we did try and shift to a virtual model of calling patients for appointments and also using Doximity, which is an app that allows video, a connection for those whose phones allow it.

And I was able to connect with several of my patients using this video app, and the majority of patients were able to connect by phone.

Many of my patients have phones, they often struggle with running out of minutes or losing their phone.

So oftentimes, the phone access is not consistent.

But I would say the majority of my patients were able to access a phone.

And I actually found that my missed appointment rate was lower using telehealth with my patients during the pandemic than it was in person.

And although this seems counterintuitive at first, as mentioned, when you think about it, it makes sense in a way that getting to a clinic appointment, people have to figure out transportation, and they have to plan in advance, and a number of things can get in the way of people making that appointment.

Whereas with the phone, they just have to pick it up, as we've learned in other populations where mental health telehealth has been practiced.

And so I was able to have meaningful connections with my patients over the phone, prescribed medications, document in our EMR.

And so I think that highlights how thinking creatively about how telehealth can be leveraged even for this population could be a way to reach a greater number of people.

So that's one lesson.

And then the other, the lesson I'll highlight is that I do think that on the whole, my patients were able to adapt to COVID.

Speaking of resilience, I was incredibly impressed by my patients' resilience during COVID.

And perhaps there is something about the fact that these individuals struggle so much with challenges every day, that they're almost more accustomed when big hits come to be able to still move forward.

And so we saw that a lot with patients who still found a way to kind of go about their daily activities and not be too affected from a mental health perspective by the pandemic in a way that I saw in other populations and settings.

And so I think there's more to be thought about there.

- I wanna ask you, where do you see the future in terms of helping people who are homeless?

Over the next five years, 10 years, where do you see us going?

- Yes, I think that ideally, we need to train more of a mental health workforce to care for this population.

There's so many barriers to doing so currently, and I hope to spend part of my career working on those barriers and trying to engage more people in this field because it is incredibly challenging but also tremendously rewarding work.

And there's evidence suggesting that only about 11% of residency programs have required rotations where people work with homeless individuals based on prior studies.

And so how do we expect residents and trainees to go into this field if they're not being exposed?

So the wonder, and challenges, and beauty of the work, and they don't have leaders and people engaged in the work to show them the way and work through some of those challenges and show them that it's still worthwhile calling.

And so I think if we can increase during residency, if we can figure out a way to change the reimbursement structure, which I know is a major barrier, but I do think that's a huge reason why people are disincentivized from doing this work.

There's a lack of adequate financial reimbursement from public insurers, as opposed to reimbursement from private practice, for instance.

I think that would help significantly with the pipeline issue.

And as mentioned, I hope we can zoom out and think about how solutions to this problem require certainly mental health care, better access to high-quality mental health care throughout their lifespan, but also a whole range of factors, including the availability and affordability of housing, of decreasing racism and discrimination in housing and many sectors of life, decreasing trauma and adverse childhood experiences.

Really taking that broad, comprehensive view is how we're going to make headwind and ultimately solve this problem.

- Katie, on behalf of all the people that you've helped and continue to help and will help in the future, I just want to say thank you so much for all that you do, and thank you for joining us today to share your extraordinary perspective on this very important issue.

- Thank you so much, Jeff.

It was a true privilege to be here.

(mellow music) - The work that Dr. Koh and colleagues are doing with people who are experiencing homelessness is inspiring and certainly worthy of the sentence, "With help, there is hope."

(mellow music) Do not suffer in silence.

With help, there is hope.

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

(mellow pensive music) (mellow pensive music continues)