Scouring the underpasses of bridges, local libraries, and the New Haven Green. Heading to soup kitchens and known locations of homeless encampments. Offering the unsheltered a no-judgment opportunity for whatever they might need.
That’s what Connecticut Mental Health Center’s Street Psychiatry team—psychiatrist Emma Lo, social worker Eileen Hamel, and program manager James Adu—are doing in “normal” times: taking mental health services to wherever unsheltered people in the city make their homes. But the global pandemic is challenging the small team that became fully operational less than one year ago.
CMHC Street Psychiatry has become intricately linked with the City of New Haven’s public health response to the pandemic. And the team is meeting the test with nimbleness at a time when the city’s unsheltered community needs them more than ever.
They’ve helped guide the mental health protocols for the city’s temporary homeless respite center at Regional Career High School. That center, known as Shelter One, was established for homeless people who contract COVID-19 and need a place to be physically distant while they recover.
They’re coordinating discharges from Shelter One, ensuring that people leave with connections to case managers who can help them get rapid housing and other services.
If that weren’t enough, they’re working with the city to create and staff the Blake Field Drop-In Center, a tent on Willow Street in New Haven that opened during the first week of May. It’s a place where homeless people can connect with medical and mental health services, take a shower at a nearby school, and get food, face masks, and other resources.
Street Psychiatry is also responding to community needs that weren't necessarily on their radar before. Recently Dr. Lo, Assistant Professor of Psychiatry and leader of the Street Psychiatry team, created a partnership with local non-profit New Reach and its domestic violence shelter, Martha's Place. Yale Psychiatry resident volunteers will soon be providing phone check-in's with the women, many of whom are struggling with isolation and uncertainty but may not be engaging around mental health issues.
Dr. Lo said it’s been a whirlwind of changes in the way the group does its work. But, she added, it’s a necessary whirlwind, one that comes with great lessons about the barriers to health care access and how to overcome them.
Now, said Michael J. Sernyak, MD, the CEO of Connecticut Mental Health Center, it’s becoming clearer than ever that Street Psychiatry’s responsive, in-the-community approach represents no less than “the future of public psychiatry.”
“Street psychiatry has been the answer to a lot of questions asked and a lot of lessons learned with COVID-19,” he said. “It’s flexible and out in the community addressing what the community needs.”
The practice of Street Psychiatry is part of the international Street Medicine movement, whose founders include Dr. Jim Withers in Pittsburgh, Dr. James O’Connell in Boston, and Dr. Jack Praeger in Calcutta, India. Lo worked with Dr. Withers for one year in Pittsburgh; she later pursued her interest in Street Psychiatry as a medical resident and a Public Psychiatry fellow at Yale. She had been laying the groundwork for Street Psychiatry in New Haven for a few years when, in August 2018, a rash of K2 overdoses swept the New Haven Green. No one died, but the crisis, which affected dozens of unsheltered people who gather on the Green every day, was a wake-up call to city officials and health care providers. There needed to be a way to help people dealing with homelessness, mental illness, and substance use disorders who didn’t have--or didn’t want--access to traditional services.
After those K2 overdoses, state and local leaders quickly recognized Street Psychiatry as a partial solution to a serious and growing problem. The team received funding for its official start-up from the Connecticut Department of Mental Health & Addiction Services (DMHAS). CMHC, a community mental health center run collaboratively by DMHAS and the Yale Department of Psychiatry, is Street Psychiatry's home.
Eileen Hamel, LCSW, who has been with DMHAS for 20 years, came to the team after spending about eight years doing forensic evaluations. She started her social work career at CMHC and felt a desire to return to New Haven. She also wanted to get back to hands-on clinical work. When the opportunity to join the Street Psychiatry team came up, she jumped at it.
“I just thought it sounded so awesome and unique,” she recalled. “I loved it immediately. We get to know clients at a depth that you don’t get with traditional clinical settings. We’re seeing how people are living. The resilience of people out there is just amazing.”
I feel like I couldn't practice medicine any other way.
Emma Lo, MD
Hamel said outreach and engagement is often a long process of developing a relationship with the homeless that is typically conducted in a casual, more intimate way. It’s a slow process, she explained, that starts with the unsheltered person’s own priorities—very often, their basic survival needs. Team members build trust over time; that trust can lead eventually to a range of case management and housing services and psychiatric treatment.
Prior to the global pandemic, Lo and Hamel did the outreach work of scouring the city and offering targeted help to the city’s homeless community about 12 hours per week. COVID-19 has cut that work down to two hours per week. The team’s caseload is now nearly half its usual size, and they can’t take new clients. In its truncated rounds, the CMHC team is giving out supplies like face masks and sharing information about the importance of social distancing while trying to assess if people have any immediate mental health needs. (To learn more about Street Psychiatry’s approach to clinical care in the time of COVID-19, click here.)
Overall, the team's work coordinating with the City of New Haven and helping to build infrastructure across various programs and services has more than made up for the dip in caseload.
Hamel sees the new Blake Field drop-in tent as a chance to run into clients they haven't seen since the pandemic began. She expects to spend time each week providing consultations for behavioral health issues and trying to help get the word out to unsheltered people who might not know about the tent.
James Adu, who joined the team last October, has worked during the pandemic with New Haven officials to develop a strategy to serve the homeless. In addition to playing a key role at Blake Field, he’s also working with the city to count its homeless population so that more hotel rooms can be secured to safely house people during the pandemic.
With a background in health care management, Adu said it's been rewarding to see how systems and services can be aligned very quickly to make access easier and to remove barriers. He is originally from Ghana, a country with approximately one psychiatrist for every one million people where, he notes, “mental health care doesn’t really exist.” In part because of his roots, Adu is keenly interested in well-designed, affordable health care systems where professionals are working together to solve problems, rather than duplicating services and creating inefficiencies.
“It's been rewarding and sort of fascinating to watch such a huge community effort with people coming together and helping each other out,” he said. Adu added that he hopes that people do not to forget about this vulnerable population after COVID-19 is over.
“The goal is to keep advocating and to find a way to improve the lives of those that would accept help,” he said.
Hamel echoed Adu’s sentiments.
“I just want people to remember our folks out there,” she said. “They're the most vulnerable people in our society in regular times, and they're the most impacted in this pandemic. Keep them in your minds…They didn't go away.”
COVID-19 or no, the rewards are great for the Street Psychiatry team. In a world where, as Dr. Lo reflected, homeless individuals too often come to be “dehumanized” and doctors experience pressure to conform to the demands of the traditional health care system, Street Psychiatry showed her a different path, one where she could be a doctor and pursue social justice at the same time.
Reflecting on the team's philosophy, she said, “I feel like I couldn’t practice medicine any other way."