Making House Calls to Those Who Have No House: A Street Psychiatrist’s Journey Supporting the Mental Health of Our Unhoused Neighbors
A Conversation with Katherine Koh
Dr. Katherine Koh is a practicing psychiatrist at the Boston Health Care for the Homeless Program (BHCHP) and Massachusetts General Hospital (MGH). She is also an Assistant Professor of Psychiatry at Harvard Medical School. As a member of the street team at BHCHP, Dr. Koh focuses her clinical care on homeless patients who live on the street through a combination of street outreach, clinic sessions, and home visits for patients recently or unstably housed. She also maintains a general outpatient practice at MGH and conducts research on mental health and homelessness. Her primary interest is improving systems of mental health care for homeless patients. She is a graduate of the MGH/McLean Psychiatry Residency Program, where she served as MGH Chief Resident as well as Chief Resident for Community Psychiatry. She earned her medical degree from Harvard Medical School. She received a Master of Science in Evidence-Based Social Intervention, with Distinction, from Oxford University. She earned her BA, magna cum laude with Highest Honors in Psychology, from Harvard College.
More than 580,000 people in the U.S. experience homelessness nightly. Two-thirds of the people who are chronically homeless are unsheltered. Many believe incorrectly that the fundamental cause of homelessness are mental-health problems and drug addiction. People experiencing homelessness bear the burden of comorbidities (e.g. co-occurring medical, psychiatric, and substance use disorders) which increase premature death risk. Health, racial, and economic inequity effectively eliminate unhoused peoples’ chances for better living conditions. It is noteworthy that many physicians are unprepared to respond to these patients’ needs. It is now appreciated that the confluence of poverty, structural racism, and siloed care necessitate interprofessional collaboration (e.g. among physician assistants, nurse practitioners, psychologists, psychiatrists, dentists, social workers, and case managers) to address homelessness effectively. Boston Health Care for the Homeless Program (BHCHP) is such a collaboration.
Martin Goldstein: Thank you Katherine for your time and for sharing important insights about health and homelessness with the Social Impact Review today. For many living in a city, whether it be New York, San Francisco or Cambridge, MA, we see people every day sleeping on the street. As a mental health physician treating homeless people, who are these people?
Katherine Koh: People experiencing homelessness, are courageous, resilient, kind individuals who have experienced unimaginable life adversity, and found a way to keep moving forward with their lives. Unhoused people are a heterogeneous population. The modern-day homeless population includes women-led families, children, veterans, and racial minorities, who are vastly overrepresented in the homeless population.
It's understandable that people who have not interacted with homeless people have misconceptions about them, as society has stigmatized them. I have had the privilege of getting to know people experiencing homelessness. They have brought me into their worlds, and I have become captivated by their stories, their humanity, their hardships, their perseverance.
These people are just like you and me, with struggles, hopes, and dreams. Unfortunately, they have been dealt a bad hand with limited opportunities that led them to be where they are today – on the street. From a mental health perspective, there are many misconceptions about people without housing, for instance that most have schizophrenia. However, that belief is not supported by evidence. People who are homeless have a variety of psychiatric disorders, including mood disorders, anxiety disorders, and trauma-related disorders, which are common in the homeless population. Schizophrenia does occur at a disproportionate rate relative to the general population, but it's a less common psychiatric disorder relative to other psychiatric and substance use disorders. The range of suffering from different types of mental illnesses is vast.
Goldstein: What are the causes of mental illness in unhoused people? Are the causes of mental illness in the non-homeless population the same or different?
Koh: There is a bidirectional relationship between homelessness and mental illness. Many think mental illness leads to homelessness, but importantly homelessness can lead to mental illness as well.
Many people who become homeless have pre-existing mental illness that was not treated appropriately or was exacerbated by other factors, such as poverty or adverse childhood experiences (ACEs) or loss of a relationship. It's not mental illness itself, but lack of systems of care for people with mental illness that leads to homelessness.
Homelessness itself is such a challenging, often dehumanizing, traumatic experience that people who don't suffer with mental illness can develop a mental illness like post-traumatic stress disorder (PTSD), or an existing mental illness can be exacerbated. Homeless people also struggle significantly with substance use disorders. Many homeless people say they use substances merely as a way to survive the hardships of the street. Life on the streets is such a difficult way to live that using alcohol or opioids can feel as if it helps them get through the experience and feel a little bit less of the pain of living every day. The frame of a bi-directional relationship is a helpful way to think about mental illness and homelessness.
Goldstein: What are the differences in providing healthcare to homeless and non-homeless patients or residents? What are the clinical needs and the rules of engagement for the two populations?
Koh: In addition to my work as a street psychiatrist treating homeless people, I also work as a general adult psychiatrist at Massachusetts General Hospital (MGH), where I care for non-homeless patients. I am able to compare and contrast and see first-hand the disparities that people on the street face. For example, the mortality rate amongst people on the street is significantly greater. About forty unhoused patients that we follow die every year, or one patient every 1-2 weeks. In my MGH clinic, over the past four years, one patient has died over that entire time. Every death is hard, and every death is meaningful to me. The frequency of death in my street patients is still hard for me to wrap my mind around. And the inequities continue even after people die. Oftentimes there's no funeral, there's no obituary, there's no family to claim the body of the unhoused person. There is no autopsy, as autopsies for the homeless population are not prioritized. Not knowing the cause of death is clinically difficult, because we can't alter our practice based on cause-of-death data. Our team has created an annual memorial to give homeless people the dignity they deserve even in death.
The clinical needs are also different between the two populations. In my MGH clinic, non-homeless patients frequently ask about sleep medication. For unhoused people living on the street, sleep medications are not desired. They often avoid sleeping deeply, as there's a risk of being robbed or assaulted overnight. Not sleeping well on a repeated basis adversely affects the mental health of people without housing. This highlights the impact of social circumstances and environment in people's mental health and how much they are intertwined.
Finally, the rules of engagement and care are different for people without housing. At the MGH clinic if a housing-secure patient misses multiple appointments in a row, or has a pattern of being late, we are encouraged to talk to them about changing their behavior. If they fail to change, they are often terminated. That requirement does not work well for unhoused people as they live chaotic lives. People experiencing homelessness who come to our walk-in clinic will never be denied care because they miss an appointment. In fact, that's a sign that an unhoused person needs more help and engagement and proactive outreach. That is a lesson-learned that I apply to treating housing-secure people, to be more flexible, working with them to develop a plan to keep appointments in a timely manner and not terminating them from care.
At the end of the day however, there are still universalities and commonalities between the populations that I find beautiful. Both unhoused people and housing-secure people have a fundamental human need to be cared for, to be seen, to be understood. People want to matter. Each person is a universe unto themselves, filled with life experiences. People want their story to be known and heard. These principles are valued by both populations and require attentive listening, support, perceptiveness, and affirmation on the part of the treating psychiatrist.
Goldstein: You bring such compassion and emotional awareness to your practice. What prompted you to pursue psychiatry for homeless patients?
Koh: I've given that a lot of thought, in part because psychiatry as a field prompts and encourages self-reflection. This work feels like a calling for me. I was born into the opposite of homelessness. I was given everything a child could want in life: good health, a wonderful education, a safe neighborhood, awesome siblings, and most importantly two extraordinary and loving parents. There are so many ways to be privileged in life. But one way that's not talked about enough is having loving role models, who provide support, are present, and involved. Despite their busy careers, my parents always prioritized their children and instilled values. My dad's family is from Korea. My mom's family is from Lebanon. They taught us how fortunate we were to be here, how much was sacrificed, and encouraged us to be aware of those privileges, to carry that forward in our lives, and to give back to others. My home was a place of safety, refuge, and stability.
In that context, I went off to college with homelessness not on my radar. I hadn't interacted with anyone who was homeless. I hadn't really seen it much. Surprisingly, there's actually a striking prevalence of homeless people in Harvard Square. Seeing people living in abject poverty in the shadows of the richest university begs the question – how does that happen? The contrast was something that I found profoundly wrong. I clearly remember the first time I talked to a homeless person. My friend and I were at an event, and there were leftover strawberries. We decided on a whim we would give it to this man sitting on the sidewalk in front of a bookstore. I still remember feeling trepidation. I’m ashamed to admit that now. But like a lot of people, I had misconceptions that this person may be deranged or would be difficult to speak with. But it was actually a strikingly normal conversation. We talked about the weather. We talked about the Red Sox. He was grateful for the strawberries. That interaction shattered so many misconceptions I had about unhoused people. I realized that unhoused people were just like me. They just happened to have had a completely different set of life circumstances. Had I not been so fortunate to have been born to my beautiful family and circumstances, I could have easily been in their shoes.
Those feelings of good fortune and opportunity are the backdrop for all my subsequent interactions working with unhoused people. I started volunteering for Harvard Square Homeless Shelter and Boston Healthcare for the Homeless Program (BHCHP) and fell in love with the work. To this day, it's an animating principle to strive to give my patients the healthy and supportive relationships that my parents gave me, that I feel my patients were denied through no fault of their own. Psychiatry at its core is about understanding the complexity and beauty of human beings, their relationships, their self-identity, and how they move through their world, in addition to treating their mental illness.
Goldstein: Help us understand the practice of street medicine and street psychiatry.
Koh: Street psychiatry and street medicine are forms of medicine that proactively bring care to people who live on the street who would likely not be accessing or receiving care otherwise. People experiencing homelessness, due in large part to the trauma they've experienced throughout their lives, can have difficulty trusting people. Oftentimes they have difficulty interacting with the health care system due to negative past experiences. Some people with mental illness lack insight into what they're experiencing. Sometimes they don’t know that help is out there or how help can make a difference in their lives. And so, the model of care that we practice brings care to people, rather than waiting for them to seek it out in a traditional clinic or medical setting. Street psychiatry in particular focuses on meeting people on the street, building relationships, earning trust, getting to know people over time. So much of what I do is build those relationships before I can even get to the point of the clinical work, before I can acquire a deeper understanding of their psychiatric history and psychiatric diagnosis. And oftentimes that process can take not only days or months, but even years.
Goldstein: Do you have an actual office?
Koh: We first meet people on sidewalks, under bridges, in alleyways. We also have a walk-in clinic at MGH for people experiencing homelessness, a more traditional doctor’s office. The long-term goal is to provide people living on the street a place where they're receiving care regularly. Ultimately, many people we first meet on the street do come to the walk-in clinic, and I see them on an every two-week or monthly basis. Some people experiencing homelessness are also seen regularly but not in an office. For example, one of my patients doesn't like to come to the clinic and doesn't like to talk on the phone. But he loves to meet in a church basement. So every 2 to 4 weeks, we'll meet in a church basement where he feels most comfortable. That's where we have our visits. I’m able to provide high-quality clinical care in that basement, talking about his feelings, experiences, symptoms, and medications. He's very medically ill now, making those visits are even more sacred.
We have various clinical settings, so in addition to street outreach and the walk-in clinic, we also do home visits, a wonderful and enriching part of the work as well, in that we follow people into housing. Transitioning to housing is a precarious and fragile time. Having those pre-established connections with the team can make a difference in easing that transition. I learn so much about people seeing them at home. Seeing what's on the wall, pictures, artwork, both what’s there and not there. Sometimes I learn about patients’ medication adherence. One patient who I thought was taking his meds had 70 disorganized pill bottles. We realized he had difficulty managing them, so we arranged for a visiting nurse after that appointment as an intervention. Sometimes there are cigarette butts or vodka bottles that give us a sense of people’s substance use. Home visits provide clinical insights and enrich our understanding of our patients both clinically and socially – who they are as human beings. Interacting over time in different settings is like painting a mural together, with every interaction being a stroke of a paint brush. Over time that mural becomes clear. That's something really beautiful about the work.
Goldstein: In December 2022, the Biden-Harris administration released a report called All in: The Federal Strategic Plan To Prevent Homelessness. A centerpiece of the plan is housing. Having visited unhoused people in their homes, is housing the critical touchstone for addressing homelessness?
Koh: Housing is a critical part of the solution to address homelessness. The lack of affordability and availability of housing is a primary driver of homelessness. Homelessness absolutely cannot be solved without addressing housing. Housing is a critical part of solving homelessness, but housing has to be done correctly with the right support for a person to be able to stay housed. There are also other factors at play that contribute to why people live on the street which can’t be ignored. We have to shift our focus more upstream to these earlier life determinants that lead people to be on the pathway to homelessness, including adverse childhood experiences, poverty, racial inequities, and lack of availability and affordability of mental health care for those with mental illnesses to truly nip this problem in the bud. Homelessness is complex and must be addressed in a multi-modal way.
Goldstein: Inequities, failing life determinants, lack of affordable housing are systemic problems. How would they be addressed to prevent homelessness?
Koh: Each of those has to be tackled in a different way. For instance, adverse childhood experiences (ACE) are negative events that occur in a person's life before the age of 17, and predict a whole range of negative physical, mental, and life outcomes. ACEs are present in 90% of the homeless population. Data in the literature suggests that over half the people experiencing homelessness have four or more ACEs. And there are targeted interventions like the Family Nurse Partnership, Triple P, and Incredible Years Programs that have been shown to prevent ACEs (prevent ACEs or offer protection post-ACE). If we can identify those people who are at risk for experiencing ACEs then I do think we could help prevent that pathway towards homelessness. Early life trauma has profound effects on the brain and psychological functioning. It affects how people interact with others, their ability to form healthy relationships, their ability to regulate their mood, and their ability to tolerate stress. Many unhoused people I treat are suffering from the long-term effects of trauma. Unhoused people's difficulty in relating, initiating a housing search, and using substances can often be linked back to trauma, and having not developed life skills that are needed to thrive.
Focusing on ACEs is critically important. The other factors, increasing availability and affordability of mental health care, preventing racial inequities, and poverty are systemic issues that require multi-factorial solutions themselves. All of them are key components that must be addressed to prevent homelessness. Targeting people at high risk for becoming homeless at critical transition points also has been shown to make a difference in preventing homelessness. Three populations that are at high risk for becoming homeless upon transition points based on evidence are: children aging out of foster care, people leaving jails and prisons, and soldiers leaving the army. I have conducted research with a team developing a prediction model that can predict with a high degree of accuracy soldiers at highest risk of becoming homeless upon leaving the army. The next stage is to develop a case management intervention to target those high-risk individuals and provide them with wrap-around services. The hope is to prevent them from becoming homeless. Previously there was an inability to identify with accuracy who's most likely to become homeless. With advances in methodologies like machine learning, that allow for better predictive accuracy, we can make headway in this area and provide needed support to those at highest risk.
Matt Nathan: Your work developing predictability factors for people at risk in transition is especially important with respect to veterans transferring out of the services. In your models for soldiers transitioning, did you find any correlation between those who had deployed and saw combat versus those who had not been stationed in combat zones?
Koh: What we found was the three strongest predictors of becoming homeless were: having a lifetime history of depression; a lifetime history of PTSD; and having a trauma of seeing a loved one murdered. We assessed combat exposure, and it was not found to be a significant predictor in our study. However, of note since lifetime history of PTSD (therefore could have occurred both during and prior to service) was found to be one of the top 3 predictors of homelessness in our study, it may be that it is not whether or not the soldier had combat exposure, but the response to it that determined risk of homelessness. It’s also important to note that ours is just one study, and prior studies have been mixed about whether combat exposure has been found to be a significant predictor of homelessness in veterans, so more research is certainly needed.
Goldstein: The COVID-19 pandemic has had an impact on the non-homeless population with an increase in mental illness. How did the pandemic impact unhoused people? And how did it change your practice?
Koh: This question does not have a simple answer. There were certainly people, homeless and non-homeless, who had an exacerbation of their symptomatology and their mental illnesses because of the COVID-19 pandemic. For example, one patient’s day program shut down, which triggered a depressive episode that he still hasn't fully recovered from years later. The day program is still not open. It was a source of connection, meaning, and purpose in his every day. I saw that mirrored in the general population. Interestingly, at the same time, I also observed that some unhoused people were actually less affected by the pandemic than I would have anticipated. People without housing carried on with their lives. Relative to the general population, many seem to have been bothered less. One hypothesis is that people experiencing homelessness are so used to dealing with adversity, hardship, and threat every day that the pandemic just felt like another hardship. This hypothesis hasn't been studied in a rigorous way. For now, it is a working theory, but an observation that piqued my curiosity clinically.
Goldstein: Is an unhoused person’s capacity of resilience greater than the resilience of a non-homeless person? Did you see a change in your practice during the COVID-19 pandemic?
Koh: People without housing have unimaginable resilience. They have learned how to cope with circumstances that most people wouldn't survive. Unhoused people often demonstrate a focus on just getting through every day. As for COVID-19, some may have focused less on this threat than those stably housed because they had to focus on basic survival and immediate needs – finding food, shelter, and clothing. It adds more complexity to worry about something that is maybe abstract. There are a lot of working theories around that.
In terms of how the COVID-19 pandemic affected my clinical practice, there was a notable shift to trying telehealth in the unhoused population. It may sound like an oxymoron, but I think our experience showed that it can be a creative way to reach a hard-to-reach population. We should be thinking more about how to leverage telehealth and mobile technologies for unhoused people. I found it to be effective in many ways, particularly for patients who were unstably housed, or patients who had a phone as opposed to patients on the street who are less likely to have a phone. For my patients experiencing homelessness who come to clinic, I found that my missed appointment rate was down using telehealth relative to in-person visits. Many people actually preferred the phone appointments. For unhoused people, it is often hard to make appointments in person, having to factor in transportation, time challenges, and the chaos of living on the street. Simply picking up your phone is a much lower barrier to getting mental health care. There was also a small subset of people who were even able to use video technology.
For folks who didn't have their own phone, we would use creative ways to reach them via telehealth. For example, we contacted the Pine Street outreach workers to use their phone to connect with the people on the street. Visiting nurses at people's homes for those unstably housed were also a great help. We used our partnerships to help give people technological access and other choices. Mental health care, as opposed to other fields of medicine, often has less of a need for labs, imaging, or hands-on in-person contact, so mental health can be delivered by telehealth more naturally than other fields of medicine. There are a few unstably housed patients who even now prefer telehealth, and so I still do video visits with them.
Goldstein: How do you develop trust in unhoused patients who may be mistrustful of structure, healthcare and society generally?
Koh: I think so much is about following their lead and going at their own pace if you have the ability to do so. Very often, I’ll meet a person on the street, and there will be a range of reactions. Some people are hesitant to even talk, whereas some people are eager to tell you their whole life story. Responding requires emotional intelligence, meeting each person where they are, walking with them on the journey forward, and supporting them in whatever way you can. So even people who don't want anything to do with us initially, we will never give up on them. We'll keep them on our radar and over time, if there seems a good moment, we will try to re-engage. Hopefully over time there will be some eye contact, a wave, or a smile, and that is progress. For example, our team tried to engage one homeless person on the street for 7 years. When we met him, he initially didn’t want anything to do with our team. We kept him on our radar, and slowly over time we developed a rapport. One day last year he walked into our clinic with dental pain. That was his presenting issue, as he told us the pain just became unbearable. He needed somewhere to go for help. After seven years of minimal interaction on the street, he is now engaging with our team regularly. He's now on a pathway to housing, working on sobriety, and getting mental health care. He is an example of why we will always have hope and never give up on people.
Another example is a woman I met and asked her during one of our initial conversations about whether she had received mental health care. The next few times we saw her, she would not talk to me, because I realized she did not want to talk about anything clinical. Over time, I slowly began to build back rapport by talking about what was meaningful to her, which are the current events that she loves to talk about. She's well-read, goes to the Boston Public library, and reads and takes notes on news websites. That's what we talk about now. I enjoy those conversations. She's insightful and intelligent and has a passion for talking about whatever is the latest topic. The hope is that over time, she'll grow to trust me enough that she will accept psychiatric care. Those are two examples of following unhoused housed patients’ lead, and walking with them in whatever way feels best and most comfortable to them.
Goldstein: Do you apply those lessons of building trust to your non-homeless patients?
Koh: Yes, absolutely. There are people within my MGH clinic who still have trouble with trust. Many times people don't want to share the trauma they've been through or a conflict that is bothering them. The hope is by developing longitudinal relationships built on kindness and respect, we will paint that personal mural together. And so, with my MGH clinic outpatients, I engage in a similar process. I look for the brightness in people's eyes, what makes them light up when they speak about something particularly meaningful to them. It’s a wonderful way to build rapport by asking about things that are close to people’s heart and brings them joy to talk about and think about, and discussing more challenging topics over time.
Nathan: Describe the interdisciplinary / multidisciplinary care in treating people on the street who may have trust issues of institutions and or caregivers.
Koh: The model of street psychiatry and street medicine is intentionally an interdisciplinary team and a key part of our model. Our team includes internal medicine providers, a nurse, a recovery coach, and multiple case managers. We provide interdisciplinary, co-located care. When I go on street outreach, I'm always with a partner from my team, which provides an opportunity to coordinate care in-the-moment.
Studies show that unhoused people are more likely to engage with mental health care if it's paired with case management or physical health services. Oftentimes, mental health care is not the first priority. People are understandably often more focused on housing or case management needs, and so that's what they're going to seek first. If they already have a pre-established relationship with the case manager however, they're more likely to seek psychiatric care if the case manager provides a warm hand off or can tell the patient I am a trusted resource. Another example of the power of interdisciplinary care is our recovery coach. For ten years he was homeless, with multiple substance use disorders and mental illnesses. He has completely rebuilt his life and is now able to connect with people on the street in a way that someone without that lived experience cannot. He's often a liaison for urging unhoused people to seek psychiatric care. They're more likely to trust him, and seek care if it comes from somebody they already have a trusted relationship with. In other words, two aspects that are pivotal to the success of street practice treating homeless people is embedded interdisciplinary care and the warm hand-off.
Nathan: Do popular motion pictures, such as the Fisher King, the King of Staten Island, and the Soloist help educate the population by generating empathy and interest? Do you worry they create a stereotypical picture of people living on the street?
Koh: I've seen The Soloist, with Jamie Foxx portraying a concert violinist struggling with schizophrenia. That is often the traditional conception of people with mental illness living on the street. That film brought a kind of humanity and a better understanding that people living on the street are human beings with hopes, dreams, and often great skill and talent. I think there's value to that. At the same time, I hope they don't create a stereotype that every person on the street suffers from schizophrenia, having delusions and hallucinations. As mentioned, there is a wide range of mental illnesses, symptoms, and experiences that people on the street have. So there are trade-offs. If done correctly, movies can build humanity and empathy for people without housing. But the risk is they portray people in a certain light that doesn't give justice to the full spectrum of what people on the street experience.
Goldstein: If you were to ask homeless people what they think would be most helpful to them as they navigate their daily lives, what would their answer be?
Koh: People fundamentally more than anything want to be seen, to be understood, to know that they matter, to be loved and respected for who they are. Oftentimes people will ask, what can I do to help a homeless person on the street? Should I give them money or buy them food? Almost every person who has experienced homelessness says what matters most is being looked in the eye, just hearing hello or good morning, or just an acknowledgment of their humanity, who they are as a human being. I believe that if you can honor that person's humanity and dignity, that is what opens doors for them to believe in themselves and to take those proactive steps forward to make their life what they wanted. And our street team has the opportunity to take that a step further and help guide them with that. I can help them with their mental health care. Maybe provide therapeutic strategies that are helpful or start them on a medication over time. Our case manager can help get them an ID or birth certificate that can help them on a housing pathway. Their physical health needs can be addressed by our medical providers. All of those logistical needs from different disciplines are necessary, but what's most important to start that process is that unhoused person knowing that we honor them for who they are right now. No matter what they do or say, we're still going to stand by them and try to support them as they move their life forward in the way that they want.
About the Authors:
Martin Goldstein is a 2020 Harvard ALI Senior Fellow and Senior Editor for the Social Impact Review. Martin has thirty plus years in biopharma, initially at Hoffmann-La Roche; followed by Genentech; subsequently, as founder and CEO of ViroLogic, Inc., a clinical laboratory guiding therapy of HIV-infected patients; and more recently working with venture to build biotech companies pursuing cutting edge science to develop therapeutics to treat disease.
Matt Nathan, M.D., is a 2020 Harvard ALI Senior Fellow and Senior Editor for the Social Impact Review. Matt was previously the 37th Surgeon General of the Navy and most recently a Senior Vice President for a large tertiary care healthcare system.
This interview has been edited for length and clarity.