(It's worrying that the NYT chose to publish clearly identifiable full face photos of patients in vulnerable conditions and in some cases their legal names. I've chosen to obscure the face of the patient in the photo above).
This is absolutely front line psychiatry; teams of psychiatrists, nurses and case workers visiting the camps and communities where unhoused people gather for safety and community on the streets of Los Angeles. The teams aim to provide diagnoses, medication and other treatment options for people where they're at, people unlikely or unable to seek out care in clinical settings.
These doctors are doing important work in difficult conditions, supporting people who may be resistant to treatment, transient or experiencing other severe disadvantage. As the article explains:
Street psychiatry offers a radical solution: that for the most acutely mentally ill, psychiatric medication given outdoors could be a critical step toward housing. Dr. Rab, a medical director of Los Angeles County’s Homeless Outreach & Mobile Engagement program, describes the system his team has built as an outdoor hospital, or sometimes as a “DoorDash for meds.”
Every weekday morning, 18 teams fan out across the county, making rounds with about 1,700 patients in tents and vehicles and alleyways. The teams try to persuade them to accept medication, sometimes in an injectable form that remains in the bloodstream for weeks. If clients say no, the teams return, sometimes for months, until they say yes; if they still refuse, the team can petition a court to order involuntary treatment.
Often, doctors are first encountering patients on the street when making diagnoses and prescribing and providing medication. The risks of this process are inherent.
Samuel Jain, the senior attorney at Disability Rights California, stated the program “feeds the fiction that if you just take your meds, the societal problem will go away.”
Some of the voices of dissent have been those in the psychiatric community. Dr. Joel Braslow, who worked on a street team early in his career and is now professor of psychiatry at the Columbia University Irving Medical Center, pointed to the increased risks faced by people heavily sedated by anti psychotics, and that street psychiatry achieves little overall without housing and other supports.
This is completely true. I'm a huge advocate of Housing First; give vulnerable people secure housing before attempting to address other issues. Requiring someone to detox from drugs of addiction on the streets before they can be considered for housing is naive to the point of cruetly. But for patients in the grip of acute psychosis, providing housing without first treating the immediate symptoms seems fraught with difficulty. A person may not know where they are. They may perceive being moved from their regular spots to a housing unit as a form of imprisonment.
Telling vulnerable people like this, "welcome to your new home, there's the kitchenette and bathroom, here's the card for the psychiatric clinic, give us a call if you have any issues, bye" is unlikely to work out. The NYT article highlights the case of a man who referred to himself as Yoh. Yoh had lived for years under a freeway underpass, so disengaged from his surroundings he would let people walk away with his meagre supplies of food and water, his mind on a supersonic train named the Pineapple Express on a mission to Lior.
Yoh believed his spot under the freeway, was the only place he was safe from evil orders from the C.I.A. A psychiatric social worker named Allen Ziegler spent months engaging with Yoh, finally convincing him to accompany Ziegler to a shelter where Yoh could shower. On arrival, Yoh became overwhelmed and panicked, and Ziegler drove him back to his spot under the overpass. Things worked out better for Yoh, but I recound this to illustrate the extent of issues people are facing - and how difficult the notion of patient choice is in such scenarios.
There's also the unbridgeable disconect between these doctors and their patients. Psychiatrists spend ten years or more studying and training for their role. Very little of that time is spent learning about the social determinants of health, intergenerational disadvantage, intersectionality - how multiple factors, such as racism, disability and a history of abuse - can affect a person. Very few of them would come from backrgounds of disadvantage themselves. Psychiatrists can meet people where they're physically at, in theory, but understanding how they got there and what it's like to have to stay are something else entirely.
The host of issues practitioners may not understand begins with the safety risks - primarily the risk to people with mental illness themselves, as they are far more likely to be victims of crime than perpetrators. The idea of confining people for their own safety is a vexed one. Imagine say locking up women walking down a busy road at 3am. But if those women are able to make their own assessment of the risks their freedom should be unimpeded. People with acute mental health issues often cannot make such assessments.
Ironically, the views of some in the disability rights community - that we need to respect people's right to refuse treatment and reject housing assistance - can horseshoe around to the views of those on the right, that being unhoused and rejecting medication is a lifestyle choice people are free to make (as long as they don't choose to live where I have to see them).
There are no easy answers here; there never have been. Treatment of mental health issues - and how those with mental health issues are treated - have been a problem since...well, always.
We should also give consideration to incorporating residential care facilities as part of the management plan. The old mental hospitals are spoken of with horror and for good reason; American Horror Story need not have incorporated a supernatural element to create a terrifying story out of the mental institutions of old. No one wants a return to the days of forced shock treatments and ice baths. The ideal of deinstitutionalisation was that people with severe mental illness would receive treatment in the community.
Could we not attempt a new form of in patient mental treatment? One where patients are respected, have their own clothes, and as much agency as possible?
I'm saying this as someone who has been hospitalised for mental health issues in the past decade, albeit only overnight. The lack of dignity - searching and seizing your possessions - points to that they are primarily concenred that you won't end your life while under their watch - coronial enquiries are a bummer. Never mind that your experience there might make you feel worse, liable to suicide upon release or absconding.
There is in fact already a model of residential mental health treatment, one former patients generally speak highly of. Private clinics where those with the means to afford it can seek treatment for a month or longer. That's not an option for most people. It also ties to another issue - the link between mental issues and disadvantage. No one says directly that poverty causes schizophrenia, but so much we don't know about the origin of mental illness. Whether links are causation or correlation, the increase in insecure employment, rising accomodayion etc are issues tied in with mental health.
And above all, decisions relating to involuntary treatment must be made by a panel - a panel including community members with lived experience of these issues.
I'm not saying this is the answer, but it is an option we could consider.
No one will ever say addressing pyschosocial disability and the multiple issues surrounding it are easy to fix and any solutions will be difficult and come with their own risks. But any solutions whether an individual program or societal change, whatever panel of doctors, social workers and researchers debate the issue, must include people with lived experience. I'll shout that from the rooftops.
And in an ideal world, there would be far more effort by universities to value lived experience in studying to qualify as a doctor or social worker. Universities however don't always have a grasp on let alone appreciation of what's happening in the real world. But that's a topic for my next post.
* Here's a paywall free link, if you want it.
0 Comments:
Post a Comment