Yes , if they are in a shelter. We successfully treated people in both a women’s shelter and a men’s shelter – a case history from which can be accessed at the end of this post. Our experience was in accordance with the findings of a 1991 report by Barrow, Hellman et al ” Evaluating outreach services: Lessons from a study of five programs. ” New Directions for Mental Health Services No 52, pp 29-44. The authors assessed the effects of five programs in New York City , which included a municipal women’s shelter and a transitional residence. Patients had some social stability and support and the shelter staff could help with the treatment
One service variable , direct psychiatric services , consisting of on-site services , significantly increased the odds that a patient would be linked to treatment .
This fits well with our experience as described in the story : “ The Man Who Lived on a Bench”
The man who lived on a bench
David S Heath FRCPC
Stefan lived on a bench in downtown Kitchener. Office workers would regularly offer him money, but he would politely refuse, telling them to give it to “someone who needs it more”. From time to time he was persuaded to stay at the nearby hostel for homeless men, but he refused to bathe or change his clothes, so eventually they have to ask him to leave.
He had recently been re-admitted again because of growing community concern about living on a bench in the cold weather.
A man with severe chronic untreated schizophrenia, Stefan was so polite he had avoided the mental health system completely. A touch of antisocial behaviour- walking naked in the street, or accosting pedestrians maybe –would have earned him a trip to the emergency room, certification as an involuntary patient under the Mental Health Act and…. possibly, successful treatment and housing
But, Stefan’s luck was about to change. This time hostel staff had referred him to the new Grand River Hospital Hazelglen Service: the first intensive home treatment service in Canada which I started in 1989.
This alternative to hospitalization was a direct copy of a home treatment service which operated in the 1970’s at the Montreal General Hospital. A short lived research project of psychiatrist Fred Fenton; one of the very first randomized controlled trials of home treatment versus hospital treatment, eventually it would take its place among the English, American and Australian classic studies of home treatment.
I interviewed him with Hazelglen nurse Mary at the hostel. From Stefan-an immigrant from Eastern Europe and hostel manager Conrad, I learned the following. Single, always a loner, he had worked in a factory until 13 years ago when he became mentally ill. He said he had been fired “for setting up the wrong chemical”. He had physically assaulted his sister; spent the night in jail and then ended up at the hostel showing signs of psychosis. He had been homeless for 13 years, had resisted all attempts to get him treated and had never fitted in to various group homes and hostels.
He was very unkempt and filthy with a long straggly beard and dilapidated boots. He was very thought disordered and delusional. Regarding his father he said: “ I go and see my father –he’s a doctor-he’s military and government and so forth, and all this type of thing….he just uses a short form- that’s why I don’t know his name” Regarding his mother, he said: “ she had something to do with inventing journalism-government secretaries and all that “.He said he didn’t need money; he did not know the year ,month, or date.
Stefan was showing the classic signs and symptoms of schizophrenia-the most severe of mental disorders –and in his case-it was particularly severe and chronic
How were we going to engage this man and treat him? For years, hostel workers had failed to register him for welfare benefits-or even persuade him to accept new boots. It would be impossible to improve Stefan’s lot in life without his starting regular sustained treatment with an antipsychotic medicine
Much of the success of home treatment of the severely mentally ill depends on “thinking outside the box” to find creative ways to engage patients. Sometimes this involves enlisting and using as a lever, the patient’s social relationships; with family, friends—anybody-who has what can be thought of as social capital vis- a -vis the patient. Mary -brilliant at this –came up with a plan.
Stefan’s social network consisted of Conrad -and two police officers who had taken a kindly interest in him over the years. Exerting all her charm, Mary persuaded the officers to “tell Stefan to take the injection ( a long acting antipsychotic drug that lasts 2-4 weeks ) “-not in a coercive fashion-but as friendly concerned authority figures whom he had got to trust over the years. Demurring at first—and clearly uncomfortable in this role—but realizing the promise this held, they agreed.
It worked. Stefan’s management then consisted of careful slow engagement, and gingerly optimizing his medication . Often, we had to work through Conrad; Stefan would make sure he was out when we visited. Sometimes we would catch him on the streets.
Conrad gradually reported more compliance with grooming, acceptance of money from social services, and less psychotic talk.
A landmark event came two months later: new boots!
Eventually, Stefan was enrolled in an injection clinic at the hospital and after 4 months he was discharged from Hazelglen and placed in a group home