Acad Psychiatry DOI 10.1007/s40596-015-0330-0
IN DEPTH ARTICLE: COMMENTARY
Ethics and the Treatment of the Mentally Ill, Homeless Person: a Perspective on Psychiatry Resident Training Jeffrey Stovall 1 & Sheryl B. Fleisch 1 & Hunter L. McQuistion 2 & Ann Hackman 3 & Toi Harris 4
Received: 20 August 2014 / Accepted: 12 March 2015 # Academic Psychiatry 2015
Abstract Objective The authors outline the unique ethical challenges that psychiatry residents face in working with individuals who are homeless and mentally ill. The authors also propose steps to develop effective teaching methods with residents working with these patients. Methods The authors reviewed literature relevant to the training of psychiatry residents in ethics and treating individuals who are homeless and mentally ill. Results The authors summarize current literature and, with the use of case examples, provide guidelines for effective teaching. Conclusions Teaching psychiatry residents who are working in the community with individuals who are mentally ill and homeless needs to address a number of unique ethical conflicts that arise in this area. The authors outline approaches to this teaching.
Keywords Residents . Ethics . Community psychiatry The phenomenon of homelessness among individuals with mental illness has presented many clinical and service challenges over the past 30 years. On a single night in January
* Jeffrey Stovall [email protected] 1
Vanderbilt University School of Medicine, Nashville, TN, USA
2
New York University School of Medicine, New York, NY, USA
3
University of Maryland School of Medicine, Baltimore, MD, USA
4
Baylor University College of Medicine, Houston, TX, USA
2014, 578,474 individuals were homeless in the USA, down 11 % since 2007, when the US Department of Housing and Urban Development began collecting these data. Among these homeless individuals, 40 % were unsheltered, living in cars, under bridges, in abandoned buildings, or directly outside (https://www.hudexchange. info/resources/documents/AHAR-2014-Part1.pdf). Estimates of those homeless individuals with severe mental illness range from one third to one half. The most commonly cited reasons for homelessness in this population include loss of housing, financial hardship, and the lack of community-based support services and longer-term psychiatric beds [1]. Also in evolution is a professional consensus on best practice models for services that have grown from traditional clinical services to a broader approach that includes the provision of housing and providing clinical services in the streets [2, 3]. At the same time, the field of mental health ethics has expanded. Applied to work with individuals who are homeless, ethical considerations must traverse the unique features that arise in this new terrain [4]. The issues of personal autonomy, professional boundaries, advocacy, and patient confidentiality that are frequently cited as the pillars of medical and psychiatric ethics [5] take on new meaning and stretch traditional concepts of ethical care within the context of treating individuals who are homeless. Care for individuals disengaged from health-care systems and social networks poses unique issues. Ethical dilemmas are compounded when applications of hospital and clinic-based rules are generalized to the homeless treatment environment [4, 6]. This evolution has had an impact upon education and training programs. The clinical and practice environment faced by a psychiatry resident continues to evolve at a rapid pace [7],
Acad Psychiatry
and ethical tensions that may arise in the nontraditional treatment of people with mental illness and homelessness can simply create for a resident another area in psychiatry that seems to lack definitive answers or guidelines [8, 9]. The literature has shown that only half of all psychiatric residency programs offer training in working with individuals who are homeless, and only 10 % require such training [10]. This leaves many psychiatrists without an adequate fund of knowledge or clinical experience in working with a distinct and significant population. Similar to psychiatry, emergency medicine, internal medicine, and family medicine residencies have a dearth of education in homelessness. There is no formal requirement to teach about homelessness, although a few programs have integrated short elective experiences into residency or medical education programs to improve attitude and improve perceptions toward homeless persons [9, 11, 12]. In this article, we will discuss ethical dilemmas that may arise in working with individuals who are homeless and mentally ill. Finally, we propose teaching methods for working with residents in these clinical settings.
What Are the Standards for Ethical Care? In considering the ethical basis of treating individuals who are homeless and mentally ill, it is crucial to approach the issue with a theoretical framework that provides principles for recognizing and debating ethics. One such set of principles frequently and familiarly used in medical treatment and in resident training is autonomy, justice, nonmaleficence, and beneficence [5]. Other ethical theories are also applicable; however, the authors have found this set of principles to be one that psychiatry residents are familiar with from other areas of their medical training. The primacy of individual liberty in making decisions affecting one’s health care is encompassed in the principle of personal autonomy. This right to self-determination is based on the assumption that treatment decisions, including when to begin and when to end treatment, are based upon competent and uncoerced reasoning, and that treatment is maintained without surveillance or monitoring. The individual has the right to refuse treatment [4, 13, 14]. Persons who are homeless may present dramatic examples of the consequences of refusing help. For instance, a clinician may work with an individual who has significant physical limitations but chooses after a medical hospitalization to return to a campsite instead of transitioning to a nursing facility, stating a preference for the freedom the campsite offers. It can be extremely difficult to negotiate the line between respect for an individual’s autonomy and an intervention to provide protection, and the tension that arises may challenge our commitment to a collaborative and recovery-based approach to treatment. Justice encompasses the principle of a fair distribution of resources to those in need. This principle also includes equal
access to treatment [5] and is often a motivating force for staff in their work and advocacy with individuals who are homeless. Psychiatry residents new to work in a system of care for individuals who are homeless may quickly feel a betrayal of their sense of justice as they work with someone who is destitute and on the periphery of the health-care system. Other residents may allow their inspiration to carry them to boundary violations or becoming overly involved in rescuing an individual. Conversely, they may become demoralized by the magnitude of a patient’s challenges and give up on hope for clinical improvement. Beneficence is the principle of providing benefit to patients, to relieving suffering and promoting well-being [5]. This principle can collide with the principle of personal autonomy when, for example, treatment refusal seems to be based upon impaired decisional capacity. When should physicians be paternalistic and step in versus allowing the individuals they are serving to decide for themselves? Nonmaleficence is the ethical principle of doing no harm to the patient [5]. Staff who are working in clinical environments with individuals who are homeless and mentally ill often work in a world where expectations to do no harm to the patient coexist with expectations that the clinician’s role is also to protect the community from harm from those who are homeless. This may arise, for example, from local businesspeople or police who contact the homeless outreach team because of behaviors perceived as being a nuisance. Statutes against loitering or trespassing intended to protect public safety run counter to the need of someone who is homeless to live in public areas. Even with these four principles of ethical care, ethical standards are dynamic and reflect societal priorities, community standards, and clinical situations [15]. In fact, alternate principles of compassion, humility, and fidelity have been proposed to encompass work in community-based systems and to provide a framework for moral discourse among front-line providers [6, 14].
What Is Unique About Treatment Settings for Individuals Who Are Homeless and Mentally Ill That Causes Tension with Traditional Ethical Standards? Case 1 Mr. R. is a 35-year-old man with a long history of schizophrenia. He consistently declines medication, leaving him delusional and unable to live around others in supervised settings. When the community treatment team began to work with him, he reported that he had found his own housing. Team visits found him living in an abandoned trailer, where he had rigged up a supply of water and a wood stove for heating and cooking. The treatment team concluded that in spite of his unconventional living situation and persistent symptoms, he
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showed an ability to care for himself. This treatment team’s decision, however, is regularly questioned by new members of the team, who assert he should be involuntarily hospitalized. In this case, the treatment team has tried to balance ethical principles at the extremes between autonomy and beneficence. The team is also aware that this balance can shift, with changes in Mr. R.’s environment and his responses to it, and therefore maintains close contact with him. A psychiatry resident joining the team may see the situation in more stark terms as he or she adjusts to the many differences working with individuals who are homeless. Being unaccustomed to such dire living circumstances and with a foundation of work in settings such as hospitals that place an emphasis on symptom remission and the physician’s role in treatment, the resident may see this balance between autonomy and treatment as admission of failure on the part of the treatment team. For even an experienced psychiatrist, determining when a mental illness is sufficiently impairing so as to require treatment is challenging. The setting where a psychiatry resident joins a treatment team is vastly different than the traditional clinic and hospital settings where their training has taken place. Working on the street or in a shelter raises questions not usually encountered in a clinic about confidentiality, personal safety, and a patient’s autonomy. In addition, the psychiatrist’s role includes a revised view of advocacy for an individual patient or group, requiring the trainee to step outside of the usual confined role as a physician. It is difficult to work with individuals who are homeless and mentally ill and remain passive, staying comfortably behind the white coat of being a physician. The role of psychiatrist is therefore modified and molded into someone who consistently and actively advocates for the patient within health and human services systems by making referrals, accompanying patients to appointments, and connecting them to legal counsel as needed. The role as a psychiatrist will also broaden as one advocates within mental health systems and legislative channels for changes to accommodate the needs of individuals who are homeless and mentally ill. Psychiatry residents may struggle with this role as an advocate, not recognizing that this can be an essential and rewarding responsibility of a physician. Working in community-based settings with individuals who are homeless, the psychiatrist is confronted with the realities of money, drugs, and alcohol, and the ethics of ordering the coercive step of establishing a payee-ship. Little confronts a trainee more directly than the decision to remove control of an individual’s money from his or her own hands. The relationship that an unsheltered mentally ill homeless person has with the treatment team is unique. Often disaffiliated and symptomatic, the individual may have developed a keen sense of mistrust from living and surviving on the streets. The working relationship with individuals on the treatment team is frequently hard won, tenuous, and long in coming. A win for both sides may be as simple as the acceptance of a pair of socks, a sign that the person who is homeless is willing to
meet again. The need to be a real object for a disaffiliated population and the need for boundaries will confront the psychiatry resident with an intense countertransference reaction.
What Does a Psychiatry Resident Bring to His or Her Work That Might Heighten Ethical Conflicts? While working in community settings with patients who are homeless and mentally ill, trainees will likely encounter individuals from diverse cultural, racial, ethnic, and religious groups, both among patients and outreach staff. Expectations and experiences of a psychiatrist’s actions may take a new meaning through different cultural, racial, and ethnic lenses and require a heightened level of awareness on the part of the psychiatrist. The culture of homelessness itself may be a form of culture that is unknown to a resident. Living in shelters and by shelter rules, living with high levels of violence, and developing unique social relationships shaped by being homeless, leave the individual who is homeless and mentally ill living a cultural world apart from that of the psychiatry resident. The resident may feel disconnected from or lost in this seemingly alien community-based culture, and misunderstandings can easily occur. For residents who are themselves immigrants, there may be additional language or cultural obstacles to address in supervision. As in working with any patient who is severely mentally ill, a psychiatry resident may develop strong countertransference reactions to their patients who are homeless and mentally ill. The resident may react with a heroic zeal to fix or rescue the individual patient. The response may also be one of nihilism based on either blaming the victim or lacking confidence in one’s own abilities in the face of seemingly overwhelming need. After training in hospital-based settings, the resident may be uncomfortable working in less hierarchical treatment teams. In community-based settings, the psychiatrist may either be in a role of one of a team of equals, an outsider, or as someone with only a very narrow role as prescriber. While a psychiatrist with years of experience in the community may have developed a role, a respect, a tolerance, and an ability to work in a team with finesse, grace, humility, and professionalism; the psychiatry resident is more likely to approach working with the team expecting a ready-made acceptance as the physician. Case 2 A new third-year psychiatry resident, Dr. S., originally from a small village in India, joined a well-established, communitybased outreach team. After several days of accompanying the team psychiatrist on outreach visits to parks and underpasses, he seemed to take to the work enthusiastically. One morning, he mentioned having seen one of the patients the night before and revealed that he had been making visits during evenings
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and weekends without coordination with the treatment team. He seemed unable to identify the safety and ethical concerns this posed. He failed to recognize that he was neither licensed to work independently nor making visits under the supervision of an attending, or that there were potential concerns about his safety. The attending psychiatrist applauded his initiative and good intentions. However, she exercised leadership and provided him with clinical guidance and education, helping him to delineate his roles and responsibilities with the treatment team. The attending psychiatrist also took the opportunity to inquire about how health care was practiced in his hometown. Moreover, she discussed similarities and differences between how health care was provided in different countries and the influence of culture upon medical practice. The resident’s error in judgment provided an opportunity for an open discussion about various types of ethical pitfalls that a psychiatrist can encounter when working with this patient population, and allowed the resident to consider cultural and ethical issues that had arisen at other times in the residency training.
How Can We Better Educate Residents to Address the Ethical Issues Involved in Treating Individuals Who Are Homeless and Have Mental Illnesses? Ethical principles of autonomy, justice, nonmaleficence, and beneficence require constant attention and discussion among all engaged in clinical work. This is intensified further for psychiatry residents and early-career psychiatrists working in less-familiar clinical settings with individuals who are homeless and mentally ill. Yet, many psychiatrists work successfully with individuals who are homeless and have mental illnesses. More psychiatry residency programs are including some clinical exposure to working with patients who are homeless [10, 16]. However, there is no consensus in the field as to the appropriate method of teaching psychiatry residents how to navigate the ethical waters they will face in providing treatment to patients who are homeless and mentally ill. We propose a framework for the training of psychiatry residents. (1) There is an academic, professional, and research basis for the work psychiatrists do with individuals with homelessness and mental illness. Exposing psychiatry residents to this academic work will serve to legitimize the work and place unfamiliar practices into a professional context. This can be accomplished through seminars and courses. In addition to formal didactics, it is important to establish clinical guidelines for the day-to-day supervision of trainees working with homeless people. (2) Residency programs can identify faculty members who work in settings with persons who are homeless and support their efforts to provide an optimal education experience for trainees. Including community-based
(3)
(4)
(5)
(6)
(7)
psychiatrists as standing members of the faculty with teaching roles through training can serve to legitimize their work and provides the resident with teaching approaches similar to their work on inpatient units, consultation services, and outpatient clinics. Education should focus on biological, psychological, and sociocultural aspects of care. This approach is useful and necessary but also can help tie what the resident is learning, practicing, and experiencing back to the work done on inpatient wards and outpatient clinics. A continuous framework of patient care and service delivery in various treatment systems would allow residents to pull forth skills they may have already learned when working in different settings and with different groups of patients. Although the work may look different in different settings, and is different to some degree, there are commonalities involved wherever clinicians work with a patient. In this way, working with persons who are homeless and have mental illness or substance use disorders is instructive of techniques, especially concerning engagement, that apply to working with all patients. Supervision should clarify the role and importance of boundaries in the midst of new clinical environments. High-quality supervision from an experienced attending can help the trainee learn to minimize the risk of coercion of the patient and to provide safety to the patient and to themselves while prioritizing a therapeutic relationship. This supervision can help to delineate the line between the right of autonomy and the occasional need for coercive interventions, such as involuntary hospitalization or establishing a payee-ship. The attending supervisor must also realize that the trainee can learn from the interdisciplinary treatment team. Working with the team may afford the resident with firsthand exposure to the essential work provided by team members from a number of different disciplines. Ethical care is more likely to be achieved when treatment is discussed and agreed upon in a collaborative spirit. It is useful for a resident to see that others may confront and struggle with similar issues, answers are not always easily reached, and conflicts and disagreements occur and can be resolved. It is also important that residents see their supervisor grapple with these issues in the team setting, where the supervisor serves as a unique member of the team. It is increasingly recognized that residents need to learn about systems of care and their role in the system, now encoded by the Accreditation Council for Graduate Medical Education [17, 18]. This accentuates an understanding of the physician’s role as advocate. It also includes how residents might bring back what they have learned from the community-based setting into the traditionally more rigid structure of the hospital setting to provide care for persons who are homeless and have mental illnesses.
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(8) Because people with homelessness and mental illnesses typically experience extremely complex biopsychosocial challenges, especially being in urgent need of housing, the trajectory toward meeting their recovery goals is arduous and frequently takes longer to achieve than for domiciled patients. For this reason, supervision must accentuate the crucial benefits of housing and the long view—that is, that the patient is moving through a protracted but stage-wise process [19]. In fact, the longer a psychiatrist is able to work with patients who are homeless, the more rewarding the work becomes. (9) Formal teaching in psychiatric ethics is crucial. As with other aspects of training, formal lectures, case conferences, and journal clubs led by faculty members with training and experience in ethics will serve as a foundation on which to apply all encounters with patients regardless of the clinical setting.
Disclosures There are no conflicts of interest to disclose by any of the authors.
References 1. 2.
3.
4. 5. 6.
Conclusion An interested psychiatry resident can bring enthusiasm, a foundation of clinical knowledge, and fresh insight and questions that can invigorate a clinical team. Residents can find the work extremely rewarding as they come to understand that although they might not be able to achieve a fantasized sense of cure for individuals with homelessness and mental illness, they can improve the lives of some individuals immeasurably. For example, a resident can see the value of accompanying a patient with paranoia and disorganized thinking to a sickle cell anemia clinic to which he or she may have been too symptomatic to attend without support. Attending psychiatrists’ role as a teacher can enrich their experience working as part of the treatment team as they broaden the role from providing clinical care only. Patients and members of the multidisciplinary treatment team often come to respect and enjoy the presence of a psychiatry resident on the team. The task facing the attending psychiatrist is to help the trainees navigate the new ethical waters they face in working with individuals who are homeless and have mental illnesses. Implications for Educators • Psychiatry residents working with individuals who are homeless and have a mental illness face unique ethical dilemmas. • Psychiatry faculty can provide valuable and rewarding teaching to psychiatry residents in community settings where individuals who are homeless receive care. • Faculty members can take steps to help psychiatry residents navigate the ethical waters they face in working with individuals who are homeless and have mental illness.
7.
8.
9.
10.
11.
12.
13.
14. 15. 16.
17.
18.
19.
Gillig P, McQuistion H. Clinical guide to the mentally ill homeless person. Washington DC: American Psychiatric Publishing; 2006. Bauer LK, Baggettt TP, Stern TA, O’Connell JJ, Shtesel D. Caring for homeless persons with serious mental illness in general hospitals. Psychosomatics. 2013;54:14–21. Substance Abuse and Mental Health Services Administration. Behavioral health services for people who are homeless. Treatment Impact Protocol (TIP) Series 55. HHS Publication No. (SMA) 13–4734. Rockville, MD, Substance Abuse and Mental Health Services Administration; 2013. Liegeois A, van Audenhove C. Ethical dilemmas in community mental health. J Med Ethics. 2005;31:452–6. Beauchamp T, Childress J. Principles of biomedical ethics. 7th ed. Oxford: Oxford University Press; 2012. Christensen R. The ethics of treating the untreatable. Psychiatr Serv. 1995;46:1217. Yedidia MJ, Gillespie CC, Bernstein CA. A survey of psychiatric residency directors on current priorities and preparation for public sector care. Psychiatr Serv. 2006;57:238–43. Roberts L, Geppert C, Bailey R. Ethics in psychiatric practice: essential ethics skills, informed consent and confidentiality. J Psychiatr Pract. 2002;8:290–305. Morrison A, Roman B, Borges N. Psychiatry and emergency medicine: medical student and physician attitudes toward homeless persons. Acad Psychiatry. 2012;36:211–5. McQuistion HL, Ranz JM, Gillig PM. A survey of American Psychiatric Residency programs concerning education in homelessness. Acad Psychiatry. 2004;28:116–21. Brill JR, Jackson TC, Stearns MA. Community medicine in action: an integrated, fourth year urban continuity preceptorship. Acad Med. 2002;77:739. Woodhead EL, Sperry JA, Bower EH, Fitzpatick KM. Attitude change following a homeless clinic experience. Fam Med. 2009;41:83–4. Melamed Y, Fromer D, Kemelman Z, Barak Y. Working with mentally ill homeless persons: should we respect their quest for anonymity? J Med Ethics. 2000;26:175–8. Stovall J. Is assertive community treatment ethical care? Harv Rev Psychiatry. 2001;9:139–43. Appelbaum P. Ethics in evolution: the incompatibility of clinical and forensic functions. Am J Psychiatry. 1997;154:445–6. Fleisch SB, Kelly AC. Street psychiatry as a community rotation for residents: the UNC Homeless Support Program. Acad Psychiatry. 2014;38:246–7. Lemelle S, Arbuckle MR, Ranz J. Integrating systems-based practice, community psychiatry, and recovery into residency training. Acad Psychiatry. 2013;37:35–7. Widge AS, Hunt J, Servis M. Systems-based practice and practicebased learning for the general psychiatrist: old competencies, new emphasis. Acad Psychiatry. 2014;38:288–93. McQuistion HL. Homelessness and behavioral health in the new century. In: McQuistion HL, Sowers WE, Ranz J, Feldman JM, editors. Handbook of community psychiatry. New York: Springer; 2012. p. 407–22.
IN DEPTH ARTICLE: COMMENTARY
Ethics and the Treatment of the Mentally Ill, Homeless Person: a Perspective on Psychiatry Resident Training Jeffrey Stovall 1 & Sheryl B. Fleisch 1 & Hunter L. McQuistion 2 & Ann Hackman 3 & Toi Harris 4
Received: 20 August 2014 / Accepted: 12 March 2015 # Academic Psychiatry 2015
Abstract Objective The authors outline the unique ethical challenges that psychiatry residents face in working with individuals who are homeless and mentally ill. The authors also propose steps to develop effective teaching methods with residents working with these patients. Methods The authors reviewed literature relevant to the training of psychiatry residents in ethics and treating individuals who are homeless and mentally ill. Results The authors summarize current literature and, with the use of case examples, provide guidelines for effective teaching. Conclusions Teaching psychiatry residents who are working in the community with individuals who are mentally ill and homeless needs to address a number of unique ethical conflicts that arise in this area. The authors outline approaches to this teaching.
Keywords Residents . Ethics . Community psychiatry The phenomenon of homelessness among individuals with mental illness has presented many clinical and service challenges over the past 30 years. On a single night in January
* Jeffrey Stovall [email protected] 1
Vanderbilt University School of Medicine, Nashville, TN, USA
2
New York University School of Medicine, New York, NY, USA
3
University of Maryland School of Medicine, Baltimore, MD, USA
4
Baylor University College of Medicine, Houston, TX, USA
2014, 578,474 individuals were homeless in the USA, down 11 % since 2007, when the US Department of Housing and Urban Development began collecting these data. Among these homeless individuals, 40 % were unsheltered, living in cars, under bridges, in abandoned buildings, or directly outside (https://www.hudexchange. info/resources/documents/AHAR-2014-Part1.pdf). Estimates of those homeless individuals with severe mental illness range from one third to one half. The most commonly cited reasons for homelessness in this population include loss of housing, financial hardship, and the lack of community-based support services and longer-term psychiatric beds [1]. Also in evolution is a professional consensus on best practice models for services that have grown from traditional clinical services to a broader approach that includes the provision of housing and providing clinical services in the streets [2, 3]. At the same time, the field of mental health ethics has expanded. Applied to work with individuals who are homeless, ethical considerations must traverse the unique features that arise in this new terrain [4]. The issues of personal autonomy, professional boundaries, advocacy, and patient confidentiality that are frequently cited as the pillars of medical and psychiatric ethics [5] take on new meaning and stretch traditional concepts of ethical care within the context of treating individuals who are homeless. Care for individuals disengaged from health-care systems and social networks poses unique issues. Ethical dilemmas are compounded when applications of hospital and clinic-based rules are generalized to the homeless treatment environment [4, 6]. This evolution has had an impact upon education and training programs. The clinical and practice environment faced by a psychiatry resident continues to evolve at a rapid pace [7],
Acad Psychiatry
and ethical tensions that may arise in the nontraditional treatment of people with mental illness and homelessness can simply create for a resident another area in psychiatry that seems to lack definitive answers or guidelines [8, 9]. The literature has shown that only half of all psychiatric residency programs offer training in working with individuals who are homeless, and only 10 % require such training [10]. This leaves many psychiatrists without an adequate fund of knowledge or clinical experience in working with a distinct and significant population. Similar to psychiatry, emergency medicine, internal medicine, and family medicine residencies have a dearth of education in homelessness. There is no formal requirement to teach about homelessness, although a few programs have integrated short elective experiences into residency or medical education programs to improve attitude and improve perceptions toward homeless persons [9, 11, 12]. In this article, we will discuss ethical dilemmas that may arise in working with individuals who are homeless and mentally ill. Finally, we propose teaching methods for working with residents in these clinical settings.
What Are the Standards for Ethical Care? In considering the ethical basis of treating individuals who are homeless and mentally ill, it is crucial to approach the issue with a theoretical framework that provides principles for recognizing and debating ethics. One such set of principles frequently and familiarly used in medical treatment and in resident training is autonomy, justice, nonmaleficence, and beneficence [5]. Other ethical theories are also applicable; however, the authors have found this set of principles to be one that psychiatry residents are familiar with from other areas of their medical training. The primacy of individual liberty in making decisions affecting one’s health care is encompassed in the principle of personal autonomy. This right to self-determination is based on the assumption that treatment decisions, including when to begin and when to end treatment, are based upon competent and uncoerced reasoning, and that treatment is maintained without surveillance or monitoring. The individual has the right to refuse treatment [4, 13, 14]. Persons who are homeless may present dramatic examples of the consequences of refusing help. For instance, a clinician may work with an individual who has significant physical limitations but chooses after a medical hospitalization to return to a campsite instead of transitioning to a nursing facility, stating a preference for the freedom the campsite offers. It can be extremely difficult to negotiate the line between respect for an individual’s autonomy and an intervention to provide protection, and the tension that arises may challenge our commitment to a collaborative and recovery-based approach to treatment. Justice encompasses the principle of a fair distribution of resources to those in need. This principle also includes equal
access to treatment [5] and is often a motivating force for staff in their work and advocacy with individuals who are homeless. Psychiatry residents new to work in a system of care for individuals who are homeless may quickly feel a betrayal of their sense of justice as they work with someone who is destitute and on the periphery of the health-care system. Other residents may allow their inspiration to carry them to boundary violations or becoming overly involved in rescuing an individual. Conversely, they may become demoralized by the magnitude of a patient’s challenges and give up on hope for clinical improvement. Beneficence is the principle of providing benefit to patients, to relieving suffering and promoting well-being [5]. This principle can collide with the principle of personal autonomy when, for example, treatment refusal seems to be based upon impaired decisional capacity. When should physicians be paternalistic and step in versus allowing the individuals they are serving to decide for themselves? Nonmaleficence is the ethical principle of doing no harm to the patient [5]. Staff who are working in clinical environments with individuals who are homeless and mentally ill often work in a world where expectations to do no harm to the patient coexist with expectations that the clinician’s role is also to protect the community from harm from those who are homeless. This may arise, for example, from local businesspeople or police who contact the homeless outreach team because of behaviors perceived as being a nuisance. Statutes against loitering or trespassing intended to protect public safety run counter to the need of someone who is homeless to live in public areas. Even with these four principles of ethical care, ethical standards are dynamic and reflect societal priorities, community standards, and clinical situations [15]. In fact, alternate principles of compassion, humility, and fidelity have been proposed to encompass work in community-based systems and to provide a framework for moral discourse among front-line providers [6, 14].
What Is Unique About Treatment Settings for Individuals Who Are Homeless and Mentally Ill That Causes Tension with Traditional Ethical Standards? Case 1 Mr. R. is a 35-year-old man with a long history of schizophrenia. He consistently declines medication, leaving him delusional and unable to live around others in supervised settings. When the community treatment team began to work with him, he reported that he had found his own housing. Team visits found him living in an abandoned trailer, where he had rigged up a supply of water and a wood stove for heating and cooking. The treatment team concluded that in spite of his unconventional living situation and persistent symptoms, he
Acad Psychiatry
showed an ability to care for himself. This treatment team’s decision, however, is regularly questioned by new members of the team, who assert he should be involuntarily hospitalized. In this case, the treatment team has tried to balance ethical principles at the extremes between autonomy and beneficence. The team is also aware that this balance can shift, with changes in Mr. R.’s environment and his responses to it, and therefore maintains close contact with him. A psychiatry resident joining the team may see the situation in more stark terms as he or she adjusts to the many differences working with individuals who are homeless. Being unaccustomed to such dire living circumstances and with a foundation of work in settings such as hospitals that place an emphasis on symptom remission and the physician’s role in treatment, the resident may see this balance between autonomy and treatment as admission of failure on the part of the treatment team. For even an experienced psychiatrist, determining when a mental illness is sufficiently impairing so as to require treatment is challenging. The setting where a psychiatry resident joins a treatment team is vastly different than the traditional clinic and hospital settings where their training has taken place. Working on the street or in a shelter raises questions not usually encountered in a clinic about confidentiality, personal safety, and a patient’s autonomy. In addition, the psychiatrist’s role includes a revised view of advocacy for an individual patient or group, requiring the trainee to step outside of the usual confined role as a physician. It is difficult to work with individuals who are homeless and mentally ill and remain passive, staying comfortably behind the white coat of being a physician. The role of psychiatrist is therefore modified and molded into someone who consistently and actively advocates for the patient within health and human services systems by making referrals, accompanying patients to appointments, and connecting them to legal counsel as needed. The role as a psychiatrist will also broaden as one advocates within mental health systems and legislative channels for changes to accommodate the needs of individuals who are homeless and mentally ill. Psychiatry residents may struggle with this role as an advocate, not recognizing that this can be an essential and rewarding responsibility of a physician. Working in community-based settings with individuals who are homeless, the psychiatrist is confronted with the realities of money, drugs, and alcohol, and the ethics of ordering the coercive step of establishing a payee-ship. Little confronts a trainee more directly than the decision to remove control of an individual’s money from his or her own hands. The relationship that an unsheltered mentally ill homeless person has with the treatment team is unique. Often disaffiliated and symptomatic, the individual may have developed a keen sense of mistrust from living and surviving on the streets. The working relationship with individuals on the treatment team is frequently hard won, tenuous, and long in coming. A win for both sides may be as simple as the acceptance of a pair of socks, a sign that the person who is homeless is willing to
meet again. The need to be a real object for a disaffiliated population and the need for boundaries will confront the psychiatry resident with an intense countertransference reaction.
What Does a Psychiatry Resident Bring to His or Her Work That Might Heighten Ethical Conflicts? While working in community settings with patients who are homeless and mentally ill, trainees will likely encounter individuals from diverse cultural, racial, ethnic, and religious groups, both among patients and outreach staff. Expectations and experiences of a psychiatrist’s actions may take a new meaning through different cultural, racial, and ethnic lenses and require a heightened level of awareness on the part of the psychiatrist. The culture of homelessness itself may be a form of culture that is unknown to a resident. Living in shelters and by shelter rules, living with high levels of violence, and developing unique social relationships shaped by being homeless, leave the individual who is homeless and mentally ill living a cultural world apart from that of the psychiatry resident. The resident may feel disconnected from or lost in this seemingly alien community-based culture, and misunderstandings can easily occur. For residents who are themselves immigrants, there may be additional language or cultural obstacles to address in supervision. As in working with any patient who is severely mentally ill, a psychiatry resident may develop strong countertransference reactions to their patients who are homeless and mentally ill. The resident may react with a heroic zeal to fix or rescue the individual patient. The response may also be one of nihilism based on either blaming the victim or lacking confidence in one’s own abilities in the face of seemingly overwhelming need. After training in hospital-based settings, the resident may be uncomfortable working in less hierarchical treatment teams. In community-based settings, the psychiatrist may either be in a role of one of a team of equals, an outsider, or as someone with only a very narrow role as prescriber. While a psychiatrist with years of experience in the community may have developed a role, a respect, a tolerance, and an ability to work in a team with finesse, grace, humility, and professionalism; the psychiatry resident is more likely to approach working with the team expecting a ready-made acceptance as the physician. Case 2 A new third-year psychiatry resident, Dr. S., originally from a small village in India, joined a well-established, communitybased outreach team. After several days of accompanying the team psychiatrist on outreach visits to parks and underpasses, he seemed to take to the work enthusiastically. One morning, he mentioned having seen one of the patients the night before and revealed that he had been making visits during evenings
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and weekends without coordination with the treatment team. He seemed unable to identify the safety and ethical concerns this posed. He failed to recognize that he was neither licensed to work independently nor making visits under the supervision of an attending, or that there were potential concerns about his safety. The attending psychiatrist applauded his initiative and good intentions. However, she exercised leadership and provided him with clinical guidance and education, helping him to delineate his roles and responsibilities with the treatment team. The attending psychiatrist also took the opportunity to inquire about how health care was practiced in his hometown. Moreover, she discussed similarities and differences between how health care was provided in different countries and the influence of culture upon medical practice. The resident’s error in judgment provided an opportunity for an open discussion about various types of ethical pitfalls that a psychiatrist can encounter when working with this patient population, and allowed the resident to consider cultural and ethical issues that had arisen at other times in the residency training.
How Can We Better Educate Residents to Address the Ethical Issues Involved in Treating Individuals Who Are Homeless and Have Mental Illnesses? Ethical principles of autonomy, justice, nonmaleficence, and beneficence require constant attention and discussion among all engaged in clinical work. This is intensified further for psychiatry residents and early-career psychiatrists working in less-familiar clinical settings with individuals who are homeless and mentally ill. Yet, many psychiatrists work successfully with individuals who are homeless and have mental illnesses. More psychiatry residency programs are including some clinical exposure to working with patients who are homeless [10, 16]. However, there is no consensus in the field as to the appropriate method of teaching psychiatry residents how to navigate the ethical waters they will face in providing treatment to patients who are homeless and mentally ill. We propose a framework for the training of psychiatry residents. (1) There is an academic, professional, and research basis for the work psychiatrists do with individuals with homelessness and mental illness. Exposing psychiatry residents to this academic work will serve to legitimize the work and place unfamiliar practices into a professional context. This can be accomplished through seminars and courses. In addition to formal didactics, it is important to establish clinical guidelines for the day-to-day supervision of trainees working with homeless people. (2) Residency programs can identify faculty members who work in settings with persons who are homeless and support their efforts to provide an optimal education experience for trainees. Including community-based
(3)
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(5)
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psychiatrists as standing members of the faculty with teaching roles through training can serve to legitimize their work and provides the resident with teaching approaches similar to their work on inpatient units, consultation services, and outpatient clinics. Education should focus on biological, psychological, and sociocultural aspects of care. This approach is useful and necessary but also can help tie what the resident is learning, practicing, and experiencing back to the work done on inpatient wards and outpatient clinics. A continuous framework of patient care and service delivery in various treatment systems would allow residents to pull forth skills they may have already learned when working in different settings and with different groups of patients. Although the work may look different in different settings, and is different to some degree, there are commonalities involved wherever clinicians work with a patient. In this way, working with persons who are homeless and have mental illness or substance use disorders is instructive of techniques, especially concerning engagement, that apply to working with all patients. Supervision should clarify the role and importance of boundaries in the midst of new clinical environments. High-quality supervision from an experienced attending can help the trainee learn to minimize the risk of coercion of the patient and to provide safety to the patient and to themselves while prioritizing a therapeutic relationship. This supervision can help to delineate the line between the right of autonomy and the occasional need for coercive interventions, such as involuntary hospitalization or establishing a payee-ship. The attending supervisor must also realize that the trainee can learn from the interdisciplinary treatment team. Working with the team may afford the resident with firsthand exposure to the essential work provided by team members from a number of different disciplines. Ethical care is more likely to be achieved when treatment is discussed and agreed upon in a collaborative spirit. It is useful for a resident to see that others may confront and struggle with similar issues, answers are not always easily reached, and conflicts and disagreements occur and can be resolved. It is also important that residents see their supervisor grapple with these issues in the team setting, where the supervisor serves as a unique member of the team. It is increasingly recognized that residents need to learn about systems of care and their role in the system, now encoded by the Accreditation Council for Graduate Medical Education [17, 18]. This accentuates an understanding of the physician’s role as advocate. It also includes how residents might bring back what they have learned from the community-based setting into the traditionally more rigid structure of the hospital setting to provide care for persons who are homeless and have mental illnesses.
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(8) Because people with homelessness and mental illnesses typically experience extremely complex biopsychosocial challenges, especially being in urgent need of housing, the trajectory toward meeting their recovery goals is arduous and frequently takes longer to achieve than for domiciled patients. For this reason, supervision must accentuate the crucial benefits of housing and the long view—that is, that the patient is moving through a protracted but stage-wise process [19]. In fact, the longer a psychiatrist is able to work with patients who are homeless, the more rewarding the work becomes. (9) Formal teaching in psychiatric ethics is crucial. As with other aspects of training, formal lectures, case conferences, and journal clubs led by faculty members with training and experience in ethics will serve as a foundation on which to apply all encounters with patients regardless of the clinical setting.
Disclosures There are no conflicts of interest to disclose by any of the authors.
References 1. 2.
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Conclusion An interested psychiatry resident can bring enthusiasm, a foundation of clinical knowledge, and fresh insight and questions that can invigorate a clinical team. Residents can find the work extremely rewarding as they come to understand that although they might not be able to achieve a fantasized sense of cure for individuals with homelessness and mental illness, they can improve the lives of some individuals immeasurably. For example, a resident can see the value of accompanying a patient with paranoia and disorganized thinking to a sickle cell anemia clinic to which he or she may have been too symptomatic to attend without support. Attending psychiatrists’ role as a teacher can enrich their experience working as part of the treatment team as they broaden the role from providing clinical care only. Patients and members of the multidisciplinary treatment team often come to respect and enjoy the presence of a psychiatry resident on the team. The task facing the attending psychiatrist is to help the trainees navigate the new ethical waters they face in working with individuals who are homeless and have mental illnesses. Implications for Educators • Psychiatry residents working with individuals who are homeless and have a mental illness face unique ethical dilemmas. • Psychiatry faculty can provide valuable and rewarding teaching to psychiatry residents in community settings where individuals who are homeless receive care. • Faculty members can take steps to help psychiatry residents navigate the ethical waters they face in working with individuals who are homeless and have mental illness.
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