CLINICAL HANDBOOK OF SCHIZOPHRENIA

40. Housing Instability and Homelessness 421helpful “eyes and ears” in the community. Having a good relationship with the local hospitalsand pharmacies does not hurt either, nor does forming a relationship with housingproviders, including independent landlords. Showing up during a crisis where a patient ishoused goes a long way toward maintaining good relations with landlords and other tenants.5. Take a biopsychosocial approach. The homeless population is at risk for multiplemedical disorders. This, combined with poor access to care, means that many patientshave untreated, sometimes advanced medical problems by the time they are discovered.Therefore, the biological aspect of care should involve referral for a comprehensive medicalassessment, ideally at the same site of outreach (e.g., mobile medical van, drop-in center,shelter). However, a psychiatric provider can certainly do a preliminary assessmentand laboratory screening if medical care is not readily accessible. Of course, recognizingand treating the full array of psychiatric symptoms (e.g., positive, negative, cognitive, affective,anxiety-related, and trauma-related), diagnosing substance use disorders, andprescribing appropriate medications are key aspects of the biological approach to mentalillness. The psychosocial approach should involve taking a detailed psychosocial history;making a psychodynamic formulation; assessing family and other relationships; evaluatingeducational and work history; and understanding the role of religion, spirituality, andculture in the person’s life. In addition, it involves recognizing the role of homelessnessand poverty in people’s lives, in the manifestations of their illness, and in their experienceof treatment and rehabilitation.6. Consider reality. For years, homeless individuals have been sent out of emergencyrooms and inpatient units with prescriptions they cannot afford to fill and instructionsthat they either do not understand or that are impossible for them to follow due to theirillness, poverty, or homelessness. There is no excuse for this. Treatment in any settingmust take into account the patient’s social circumstances. If a clinician believes a medicationis the best one for a patient who lacks insurance and cannot afford it, he or she cangive the patient a suitable alternative, providing samples, vouchers, or contact with acompany that has an indigent patient plan. The clinician knows about public hospitals orclinics where free or very inexpensive medications can be obtained, or makes sure that apatient who needs bed rest or must elevate his or her feet has access to a bed! This mightmean keeping the patient in the hospital a bit longer, or making extra calls to find a shelter,drop-in center, or emergency housing.Many homeless people are afraid of being sedated by medication. For good reasons,they fear this will make vulnerable to street crime. Patients should be asked about this,and their concerns should be respected. As with any patient population, the clinician’saim should be to work collaboratively with the patient, using coercive means, such as involuntaryhospitalization, only when safety is a real concern.7. Employ a harm reduction approach. Harm reduction is an approach to patientcare that stems from the substance abuse field but has broader applications. The prototypefor harm reduction is needle exchange for intravenous drug users to prevent HIVand hepatitis. Harm reduction is compatible with the previous guideline emphasizing theneed to consider reality and aim for a realistic level of improvement, even if it means toleratingsome level of self-destructive behavior. For example, a patient who is actively usingdrugs might be able to avoid becoming psychotic by taking medication. Treatingsomeone who is actively using substances involves some risk unto itself, but if, in one’sjudgment, the greater harm would come from not treating that person, then one shouldtreat him or her. Too many programs exclude patients for behaviors such as active substanceuse or past violence. A harm reduction approach can be applied to psychopharmacology,substance abuse treatment, and even housing. The Housing First approach is onesuch way to apply a harm reduction approach to housing.