edited by Paulette Marie Gillig, M.D., Ph.D., and Hunter L. McQuistion, M.D.; Arlington, Virginia, American Psychiatric Publishing, Inc., 2006, 197 pages, $37.95
Dr. Field is assistant professor of Psychiatry at the University of Massachusetts Medical School and director of psychiatric services for the homeless at the Homeless Outreach and Advocacy Program, Community Healthlink, Worcester.
This well-crafted book delivers on its promise to provide a practical guide written by clinicians for clinicians. Its 14 chapters are written by dedicated and highly experienced providers of care to people who are homeless and have mental illnesses. Each chapter uses a case example to engage the reader and bring the application of key treatment principles to life. The examples are realistically complex, yet hopeful. Each chapter stands alone and imparts valuable clinical wisdom.
Reading the book cover to cover, I also appreciated threads of continuity that reinforced general principles of patient-centered care and the stages of engagement, intensive treatment, and ongoing rehabilitation. In the references at the end of each chapter, readers will find both classic and more recently published studies about epidemiology and service design for the diverse homeless population. An index makes it easier to find information after one has finished the book.
Highly experienced and novice homeless service providers, trainees, and providers working in emergency rooms, inpatient units, community mental health clinics, and correctional settings will be interested in this book. Unfortunately the homeless population is growing, and the next generation of practitioners will need skills to carry on this work. Educators may want to add this to the reading list for their courses. Anyone who is thinking about starting a shelter-based clinic, housing program, or mobile crisis team will find pertinent chapters containing program models, outcome data, and practical advice from clinicians "in the trenches."
As a practitioner in an urban setting, I found the chapter titled "Rural Settings" fascinating. The vignettes highlighted familiar issues of mistrust, poverty, and difficulty with change. The creativity of service planning and coordination in this era of limited resources was particularly eye opening and inspiring. Two lively and compelling chapters focus on the unique needs of homeless children and families.
I was most impressed by chapter 9, "Psychiatric Inpatient Settings," written by David Nardacci. He deftly integrates statistics and interesting research findings, such as the staggering prevalence of cognitive dysfunction among homeless patients and the tragic underdiagnosis of bipolar disorder among alcohol-dependent patients. Common barriers to diagnosis are reviewed, including provider countertransference responses to difficult or uncooperative patients or patients who use substances. Without preaching, he notes the ready access to diagnostic and treatment resources on most inpatient units—in stark contrast to the scarce outpatient resources available to the disorganized, elusive patient with more urgent needs for food and shelter—and the clinical gains made from a careful diagnostic evaluation and adequate medication trial or series of trials, if needed. He emphasizes the need for substantial symptom reduction before a successful discharge transition can be made. Although I greatly appreciated the "call to duty" and view of inpatient units as having a responsibility to the community, one weakness of this chapter is the minimal comment on the lack of community resources—such as housing, case management, and assertive community treatment teams—and financial pressures for shorter hospital stays. Future editions might also include prescribing advice regarding cost, number of medications, storage, and formulary limitations, because these issues impact impoverished homeless patients who cannot afford to be turned away from a bed-in program that prohibits certain medications or turned away from a pharmacy for lack of prior approval or money.
The chapters on treating individuals and families in shelters are also particularly strong. The realities of shelter crowding, lack of privacy, theft and victimization, and medication access issues may be shocking to those who have not worked in shelter settings. The importance of collaboration with shelter staff cannot be overemphasized. Working with lay staff to reduce magical thinking and punitive use of hospitalization is discussed. Perhaps the next edition can say more about how noncollaboration evolves and how providers can advocate for changing shelter admission procedures and rules that discourage mentally ill individuals from accepting shelter. The chapter on homeless veterans is filled with interesting statistics about this relatively well-studied population. It also catalogs many of the resources available to homeless veterans. More can be said about the negative attitudes or frank paranoia some mentally ill veterans have about government-connected services.
I was disappointed by the chapter on housing, which seemed to be titled wrongly. The clubhouse rehabilitation model is described, but the descriptions of other specialized housing models lack detail and evaluation, perhaps reflecting the lack of outcome research for many of these models. The new "housing first" philosophy is mentioned, and future editions will need to review how different programs from around the country operationalize this philosophy as we move from hospital diversion to shelter diversion in an era of expanding needs and shrinking resources.
My congratulations to the team of authors for this welcome clinical guide and inspiring call to duty!