CLINICAL HANDBOOK OF SCHIZOPHRENIA

420 VI. SPECIAL POPULATIONS AND PROBLEMSshould put aside the diagnostic manual and medication arsenal, at least initially, and replacethem with friendly conversation. A clinician might serve a meal, give someone awarm blanket, or try a game of ping-pong or chess to engage a person initially, before heor she becomes a “patient.” The best approach is to find out what that person wants orneeds and to try to offer some help in that area first. He or she might want housing, a job,someone to check a leg wound, or a chance to call a relative; meeting these needs, or atleast taking initial steps to do so, likely opens the door to additional treatment. When doinga history, the clinician should first take a life history—where the person was raised,where his or her family resides now, and how he or she became homeless—before askingabout symptoms and psychiatric history. The clinician tries to be warm, funny, sympathetic,and natural. Remaining professional does not require being stiff, authoritative,and distant.2. Street outreach providers should be flexible, aiming for gradual, nonthreateningengagement for some clients and rapid housing for others, while also being prepared tohandle crises. In addition to the slow process of engaging people who may not want help,or worse yet, who might feel threatened by it, outreach teams must be prepared to handlemedical and psychiatric emergencies. Besides making an assessment of danger to self orothers, a psychiatrist doing outreach must be expert in diffusing aggression, maximizingsafety of all involved (patient, clinical team, passersby), and should understand how tocommunicate clearly and persuasively with police and paramedics. To ensure that emergencyroom personnel provide adequate care, a note, and ideally a staff person, shouldaccompany the patient to the emergency room.The Housing First approach may run counter to the gradual, cautious engagementprocess most outreach teams have learned to employ, but for some clients, the offer ofhousing may be the most powerful engagement tool. There are always some individualswith SMI for whom the street is familiar and, paradoxically, less threatening than the indoors.Therefore, outreach providers should remain flexible in their approaches, heedingour first guideline, meeting clients where “they are at” both physically and psychologically.3. Be a team player. Whether part of an ACT, CTI, or outreach team, or a housing orshelter program, one cannot treat this population without the services of others. Thework requires putting aside the diplomas and the ego, and embracing the satisfaction ofworking alongside other spirited, dedicated, and experienced staff members. Fortunately,the nature of the work often “selects” people with these qualities. One should listen towhat outreach workers, peer counselors, nurses, and social workers have to say. They oftenhave unique perspectives and experiences that psychiatric providers lack. One givesback to the team by not only providing expertise in diagnosis and treatment, but alsosharing one’s understanding of the psychodynamic aspects of the treatment situation.Psychiatric providers can supervise case managers, making use of their understanding ofengagement, resistance, transference, countertransference, and termination. They canhelp manage difficult clinical situations that arise, for example, with the paranoid or borderlinepatient. In other words, they see themselves as more than professionals sitting intheir offices, writing prescriptions, and calling 911 when necessary. If their agency expectsonly this, they offer to do more.4. Be part of the community. Beyond a relationship with the clinical team, a psychiatricprovider treating homeless people is more effective if he or she is familiar with theresources in the community, such as knowing which houses of worship serve meals or distributeclothing or getting to know the religious leaders in the community. They will appreciatehaving the clinician’s phone number when someone comes into their house ofworship and is clearly in need of psychiatric help. The psychiatric provider meets with thepolice and offers to help train officers. Local shop owners and residents may even become