Monday, February 23, 2009


In psychiatry, even more than in internal medicine, we treat a lot of patients who are currently or have been homeless. From work I used to do at a clinic for homeless patients, I'm aware that there are different "levels" if you will of homelessness. There are people who stay with family or friends, people who live in motels, people who sleep in their cars, people who live in shelters, and people who sleep on the street. Sometimes whole families are homeless, but most of my patients are single. There are people who are transiently homeless, and people who are chronically without a permanent place to stay. Many are "mentally ill", but this covers a very wide range of possible diagnoses. I've met some patients with chronic psychotic disorders, often untreated, who have no family to look out for them and were homeless. Many of my patients, though, have personality disorders (usually narcissistic, borderline, or antisocial) and/or are chronic drug and/or alcohol abusers.

In psych, we refer to some of the last group as "having poor coping skills." In other words, they don't know how to be "grown-ups" as our culture and society mandates. Especially when substances are involved, their only method of coping with stressful situations may be to pop a pill or drink a bottle. They may come to psychiatric attention because of a suicide attempt or accidental overdose; sometimes they come to the emergency room voluntarily because they "feel suicidal" or "think I'm going to hurt someone". Patients in the latter group sometimes aren't admitted to the hospital, and are discharged back to the streets.

I've noticed that I have a bias against this latter group. Even though psychiatrists (and other physicians) treat substance abuse, many of us seem to think of these disorders as non-psychiatric and non-medical for some reason. It's easier sometimes to make allowances for someone with bipolar or schizophrenia than for someone who's "just drunk" or "just high" or "just a borderline". I think part of it is because there is such a large volitional component to drug use, ie, no one MADE them do the drugs (we assume), whereas no one chooses schizophrenia (although schizophrenics may choose not to take their meds, or may choose to do drugs). It's true that there is a heritable component to addiction, and also true that many patients start using substances as young teenagers (13-14 years old) before they're able to fully appreciate the consequences of their actions.

So why the bias? Why do I feel like I have a hard time treating these patients? (For that matter, I think many doctors have a hard time treating such patients). Part of it is the volition thing. Part of it is that there's a narcissism involved with substance abuse--people who are addicted care mostly about their addiction, and often (at least the ones who come to the psych ER) can be less than friendly. Some become outright abusive. Part of it is what some of these patients do to feed their habit--I've had some say they prostitute themselves, some who beg, and some who steal, and these are just the ones who talk about it. Some are on disability, which is frustrating to someone who works hard; why should they get their $3000 check per month and get to spend it all on crack?

It would also be different if these patients were asking for help with their addiction when I see them. Instead, many of them seem to be saying "the right words" to get admitted to the psych hospital because it's cold outside, or raining, and have no intention of quitting their drug of choice. This irritates me. It's a hospital, not a free hotel. If I admit all of these patients, then there's no room for the acutely psychotic patients wandering off from home or the manic who hijacked a bus.

One of my patients said something profound to me the other day. This person had been homeless in the past, and was facing discharge to the streets. The quote: "I've been homeless before, man, I've slept on the streets before. Man, when you're out there, it's like you're not a person anymore, it's like you're not a human being."

So how to balance humanity with doing the right thing, which often means denying these patients admission? I'll be honest, this is hard for me. I find this emotional balance to be very tiring. I guess just like the paging etiquette thing, I just have to keep trying. I don't have an actual solution, at least not yet.


Casey and Chris said...

I think in any career that involves the care of others there is always a category within that group that we find it hard to accept. The only thing that keeps me going is just reminding myself that I am doing the best I can and I am only human. I can't like everyone.

John said...

Interesting article.

I suppose we all walk a thin line and sometimes through no real fault some can take a wrong turn.