Dr. Katherine Arrigg Koh is a practicing psychiatrist at the Boston Health Care for the Homeless Program and Massachusetts General Hospital. As a member of the street team at BHCHP, she focuses her clinical care on homeless patients who live on the street through a combination of street outreach, clinic sessions, and home visits for patients recently or unstably housed. She also maintains a general outpatient practice at MGH and conducts research on the health and health care of homeless populations. Her primary interest is improving systems of mental health care for homeless patients. She is a graduate of the MGH/McLean Psychiatry Residency Program, where she served as MGH Chief Resident as well as Chief Resident for Community Psychiatry. She earned her medical degree from Harvard Medical School. She received a Master of Science in Evidence-Based Social Intervention, with Distinction, from Oxford University. She earned her BA, magna cum laude with Highest Honors in Psychology, from Harvard College.
1. How does the experience of homelessness affect your patients’ ability to access necessary medical care?
Every day as a street psychiatrist, I witness the tremendous social instability facing my patients experiencing homelessness. It’s hard to fathom. They are under an enormous amount of stress and a heavy cognitive load that comes from struggling to meet basic needs – worrying about where they’ll sleep, shower, or eat. My patients navigate this all while battling substance use disorder, mental illness, and the harsh realities of living on the street, which can include being robbed, abused, and dehumanized.
In this context, it is understandable that accessing medical care is not a priority for many people who are homeless. They are more focused on meeting their daily survival needs. Relatedly, the traditional health care system is not set up to meet the needs of homeless patients. Traditional medical care, particularly mental health care, relies on patients to be on time, attend appointments regularly, and navigate a complex system. When I was in residency, if a patient missed multiple appointments in a row, you would talk to them about terminating them from care. That model, however, does not work for homeless patients who have difficulty making appointments in a timely manner. Models implemented by Boston Health Care for the Homeless Program (BHCHP) bring care to people who would not receive it otherwise and are vital to making medical and mental health care available and appealing for patients experiencing homelessness.
2. When dealing with issues like housing instability, how do you convince patients to devote the necessary attention to their health?
Many times, patients I meet during street outreach are hesitant to engage in mental health care for the reasons I described. They also have a significant distrust of the health care system, due to prior negative experiences and traumas. Much of the work we do is what Mike Jellison, the recovery coach on our team, calls a “long walk.” This entails building a relationship with patients over time, even if it takes years. Oftentimes, we’ll meet a patient on the street who will decline to engage in care. We’ll keep them on our radar—which doesn’t necessarily even mean we’ll say hi to them every time we see them—but we take note of where they are. One of the many things I love about street psychiatry is that you have to use emotional intelligence to assess when to approach and engage with individuals. Sometimes, even a half a smile or a wave from people on the street suggests progress. And over time, patients build that trust and do come into clinic for care. We had a patient recently on the street who we have been trying to get to come into our clinic since 2015—for the last 7 years—but he never wanted to come in. Then this past January, he just showed up at our clinic one day wanting help with his dental pain. He is now receiving medical and mental health care from our team, no longer using opioids and working toward getting housed. Stories like that are why we never give up hope. We really do just take these “long walks,” and sometimes when you least expect it, patients are ready to take that next step forward to improve their health and life.
For patients who come to the clinic, as opposed to patients we meet on the street, it’s really about understanding each person’s unique life circumstances, goals, and dreams. The beauty of the field of psychiatry is that at its core, it’s about the complexity and individuality of each human being. I try to help my patients see how improving their mental health will help them achieve their goals and dreams. Many patients have psychiatric disorders, but do not realize or fully understand them. So sometimes, the work involves education on how their psychiatric disorders can affect their thoughts and behaviors. Sometimes, we discuss the value of various medications to alleviate suffering. Other times, we talk about the value of therapy and therapeutic strategies to change thoughts and behaviors.
Finally, I’ll add that the model of care for the street team is unique. If a patient does not show up for an appointment, we have the ability and time to go look for them. If they do not come to my clinic session, next time I’m out on the street, I’ll try to look for them and make sure they’re okay. If it’s a patient who was recently housed, we have the time to do home visits. This proactive outreach can help remind patients that we are here as partners in their mental health journey.
3. What drew you to work in this field?
I absolutely love this work. It’s often challenging, but I come home every day knowing that there’s nothing else I’d rather be doing. I feel so grateful to have a profession that fulfills and motivates me greatly. What draws me most to working in this field is the profound, meaningful human connections I’m able to make with my patients. My patients have experienced unimaginable trauma and hardship, yet their resilience and ability to move forward in life is absolutely breathtaking.
That being said, homelessness wasn’t on my radar until I went to college. I grew up in Andover, Massachusetts, which is a wonderful, safe town. I remember distinctly the first time I spoke with someone who was homeless on the street. My friend and I had leftover strawberries from an event, so on a whim we decided to give them to a homeless man in front of a bookstore. The conversation we had was so strikingly normal, despite my fears that it would be really difficult to connect with him. We talked about the weather and sports, then we went our separate ways. That moment really shattered the misconceptions I had about people experiencing homelessness. It sparked an animating principle that drives me to this day: these individuals are just like me but happened to have been born into much less fortunate life circumstances. I could easily be in their shoes if I had not been so lucky to have been born into the beautiful family I was born into. I see the core of what I do as striving to give my patients the healthy and supportive relationships that my family gave me. They have been deprived of that through no fault of their own.
From there, I was tremendously fortunate to meet Dr. Jim O’Connell, who quickly became one of my heroes and role models in this work. I volunteered with the BHCHP street team in college and fell in love with their comprehensive, thoughtful, and humane approach to patient care. I knew that I wanted to be a street physician, and I feel so fortunate over 10 years later to be living my dream.
4. What does a typical shift look like for you?
My shift varies depending on the day, which I love about my work. I do a combination of street outreach, home visits for patients who were recently housed, clinic sessions, and respite care. I love being able to see my patients in these various contexts and environments. On the street, it’s incredible how much you learn about how people live and how resourceful and creative they are. For people who are housed, home visits provide tremendous insight into their daily lives. You learn so much more about people than you would within the walls of a doctor’s office. Clinic sessions are wonderful because they allow for more comprehensive testing, labs, and imaging, which you can’t do out on the street, and respite care at McInnis House allow me to see patients when they’re sober and often more able to engage around treatment than when they are on the street and potentially intoxicated. All of these options help me understand my patients better longitudinally. I see community psychiatry and outpatient care as like painting a mural. Every interaction is like the stroke of a paintbrush. Over time, the mural becomes clearer.
5. What kind of policy changes or reforms do you feel would be most helpful to your patients?
In order to actually make policy change, we first need to expose policymakers to this population. Many people who are making policy decisions have never spoken to a homeless person. As I mentioned, my conversations with patients, especially my initial interactions, really shattered the misconceptions I had. In order to make progress, we need to lift up their voices and break down the stigma surrounding them. Policymakers need to see that these are just human beings who have had awful luck and profoundly difficult life circumstances.
Then, we need to change the way we approach housing. When I first started doing this work, I thought the main goal was to help my patients get housed, and once housed all else would fall into place for them. But the reality is much more nuanced. Often what I see is that patients get housed and then lose their housing shortly after moving in. Even more tragically, I see patients lose their lives after receiving housing. There is some preliminary evidence that risk for overdose may actually increase in the initial days after people move into housing. It’s devastating. There’s also data suggesting that chronically homeless individuals who become housed do not often show improvement in most mental, physical, or health care spending outcomes. This is counterintuitive – you would expect housing to stabilize people. To me, this suggests that the trauma, suffering, and pain these people have experienced can’t be undone just by moving into housing.
Given that, we need to be more thoughtful about creating individualized housing plans for patients, similar to medical or psychiatric treatment plans. We should consider what type of housing the patient would benefit from, where they’re housed, and what services they receive. Of course, we also need a greater supply of affordable housing and better access to it. Entitlements to rental assistance, changes to exclusionary zoning laws, and ending racist policies which have a repugnant legacy in homelessness are needed as well.
We also need to focus more upstream on primary prevention of homelessness. There is much emphasis on housing people who are homeless, but we should also prioritize preventing people from falling into homelessness in the first place. We need to focus on preventing early life individual and community determinants, like adverse childhood experiences, that are strongly associated with homelessness. We can target people at high-risk transition points, such as children transitioning out of foster care, people being released from jails or prisons, or soldiers leaving the army. I’m involved in research aiming to prevent homelessness in U.S. army soldiers, a high-risk group. We initially developed a prediction model, using machine learning methodology, that identified soldiers leaving the army who are at high risk for homelessness. We’re now working on the second phase, which is to develop a case management intervention to reach out to these high-risk individuals and prevent them from falling into homelessness. We need more design, implementation, and analysis of such interventions to prevent homelessness from happening in the first place.
6. Is there an issue in health and homelessness that you feel has not had enough attention devoted to it?
There are many, but if I had to pick one that rises to the top, I would say the lack of an equitable mental health care system for homeless patients. There is a growing focus on building systems for preventive medical care, but less so for mental health. This is a major challenge, particularly because there is an astounding psychiatric burden in this population. There was a recent meta-analysis looking at 39 studies of homeless patients in 11 countries that found the mean prevalence of mental illness to be 76%. That figure is just stunning. I would argue few populations bear greater psychiatric burden, and yet there is not an adequate system to care for these individuals.
In order to build this system, we need to address the tremendous workforce shortage of psychiatric providers and mental health clinicians caring for this population. We need to find ways to change the reimbursement system so that psychiatry residents with significant medical school debt are not disincentivized to go into this line of work. We need to increase exposure to homeless patients during residency training. We need better pipelines to actively recruit more people of color to this work.
We then need to expand non-traditional models of care such as street outreach and shelters embedded in clinics in order to reach more homeless individuals who would not otherwise seek out care on their own. Critically, we need to provide access to therapy for these patients, because so often what these patients need is healing from the wounds of unaddressed trauma. We need more quality research that evaluates the unique mental health challenges of the homeless population and how to best address them.
Finally, as I described earlier, primary prevention of people becoming homeless in the first place has not received nearly enough attention. It is not mental illness itself that leads to homeless, but lack of systems to care for those with mental illness, poverty, and other risk factors that leads to homeless. We need to shift the conversation to how early childhood trauma and life circumstances are often key drivers of people being unable to function well or maintain housing. The pathway to homelessness starts young, yet much of the focus on homelessness is on adults. We’re not going to make any significant impact in the long-term if we don’t focus on nipping the problem in the bud. Dr. O’Connell talks about homelessness being an end product of multi-system failures of different sectors in our society. We need to look at homelessness as the complex, longitudinal problem that it is and recognize that ending it requires broad and upstream solutions.
