How Improving Mental Health Services Could Reduce the Devastating Health Impacts of Homelessness

Q: What makes it difficult for patients experiencing homelessness to engage with the traditional medical system?

People are often dehumanized within medical systems, which are not well set up for people experiencing homelessness. These systems rely on patients to be on time, attend appointments regularly, and navigate a complex medical system on their own, which is often challenging for people who are struggling to meet basic needs of food, shelter, and hygiene on a daily basis.

Many patients have also had early-life trauma, making it difficult for them to trust people in positions of influence such as doctors and health care professionals. People can also lack the insight that they need medical help due to their mental illness.

For all these reasons, people experiencing homelessness often do not proactively seek care in traditional medical systems, exacerbating physical and mental health issues and contributing to an extremely high death rate for this population.

The mean age of death for people experiencing homelessness is 51 years old, nearly 25 years younger than that of the general population and an age at which Americans commonly died in 1900.

Q: What can be done to improve the way we care for individuals experiencing homelessness?

We can strive to build creative, non-traditional systems of healthcare that are more accessible for patients experiencing homelessness.

For instance, doing proactive medical and mental health outreach and embedding clinics in shelters and soup kitchens, the model at Boston Health Care for the Homeless Program, allows us to bring care to people where they are.

MGH also just launched a first of its kind, full-time clinic for patients experiencing homelessness in the Jackson building, where we can connect the patients we meet on the street to ongoing, interdisciplinary healthcare.

We should prioritize evidence-based models such as Housing First, which provides housing for people without preconditions (such as requiring completion of mental health or substance use treatment), and has been shown to increase housing retention rates.

Q: How can we honor their memories after they pass away and recognize them as individuals both in life and after death?

We can strive to understand patients experiencing homelessness as human beings with struggles, hopes, and dreams, just like the rest of us.

These individuals are just like you and me but happened to be dealt a completely different deck of cards in life, having endured extraordinary trauma and adversity from a young age.

Often, a main reason people are on the street is the long-term impact of this early life adversity, which leads to difficulty regulating emotions, challenges in finding stable employment, and substance use.

When I first started doing this work, I was so struck to realize not only the abominable death rate, but also that people experiencing homelessness often do not have funerals, memorial services, obituaries or proper autopsies after they die. People often die alone, outside, and without any family members to mourn their death.

Our street team therefore holds a regular memorial service as a way to honor those who have passed in the past year. We find this service is well attended by members of the community on the street, I think in part because it provides them with a sense of solace that they too will at least be remembered by someone if they die while homeless.

Q: How are you using your research to find better ways to improve care for individuals experiencing homelessness? Or what can research do to improve care of individuals experiencing homelessness?

My research is focused on finding ways to prevent homelessness at high-risk transition points, times at which people are more likely to become homeless, such as soldiers leaving military service. A research team and I developed a prediction model to identify who is most likely to become homeless after leaving military service and connect these individuals to an intensive case management program to prevent them from falling into homelessness.

While so much of the research, clinical, and policy focus is on housing individuals who are already homeless, we are never going to be able to nip this major crisis in the bud if we don’t focus upstream and prevent homelessness from occurring in the first place.

My research and writings have also focused on creating frameworks and identifying best practices for providing high-quality care to this population, particularly mental health care.

Understanding how to better provide psychiatric care on the street—known as street psychiatry—is an understudied area with great potential. I’m passionate about devoting my efforts toward improving the delivery of street psychiatry in years to come.