Working with the Homeless Mentally Ill

Alan Felix, M.D.

As many of you know, my "day job" consists of directing a program for homeless mentally ill men living in the Ft. Washington Men's Shelter, just a stone's throw from the Columbia Psychoanalytic Center. I am also affiliated with a wonderful agency called the Project for Psychiatric Outreach to the Homeless (PPOH), founded by Kathy Falk and directed by Gail Albert (eds. note: you know this agency; they send us those striking postcards that say "SHRINK the Homeless Population"). This agency recruits psychiatrists who volunteer their time treating the homeless mentally ill. In addition, they sponsor residents in psychiatry and fellows in public psychiatry who treat this population. Some of our members already serve as volunteers. My outreach efforts consist of monthly case conferences at agencies served by PPOH. My first consultation was with a transitional shelter in Manhattan Everyone from kitchen staff to social workers attended the conference which focused on the program's difficulties dealing with a woman with borderline personality disorder. I began by explaining some of the core principles of psychoanalysis in non-technical terms and how they can be applied to their patient population. A lively discussion of transference and counter-transference followed, focused on this "difficult" patient. Ultimately even those on the kitchen staff recognized how this woman used splitting and projective mechanisms to make some of the staff feel special while others felt unbearably abused.

We also discussed the difficulties patients have making the transition from the street or one institutional setting to another. This has been a research area of interest to me, and I have found Mahler's phases of separation-individuation especially helpful in illustrating the intrapsychic and interpersonal problems patients have when they move from one setting to another. (i.e. rapprochement crises) One very basic aim of the consultation is to demonstrate how a careful history can be used to resolve many crises and begin the process of understanding impasses of transference and countertransference. All too often, the staff of the community-based program is unaware of much of the patient's history. Through the case conference format, the source of the patient's acting out is usually illuminated. Suddenly. a "problem patient" is transformed into a person, frequently one with a long history of neglect and/or abuse. Homeless adults often come from a background of family disorganization, characterized by shifting caretakers, parental substance abuse or mental illness, poverty, and domestic violence. It comes as no surprise then that patients act out with the staff of a residential program (their new family).

In the case presented, the patient was noted to become increasingly hostile towards staff after the death of one of the residents, an older male army veteran. Prior to the conference, no one on the staff was aware that the patient's alcoholic father was a veteran. When the history was presented, the door was opened to understanding the patient's anger and grief as presented in the transference to the agency's staff.

The feedback from the case conference was very positive. I think everyone, from the non-professional staff to the professional staff in attendance, developed an appreciation of what analysts can bring to a community setting. Our most basic functions—obtaining a thorough history, linking current behavior to past events, discovering unconscious motives, understanding the roles of resistance and defense, appreciating internalized self and object representations and the affects connected to them, and recognizing transference and counter-transference in the treatment setting—these can be demonstrated to service providers in any setting. I think this is what Freud might have had in mind when he wrote of the potential contribution of psychoanalysis toward the resolution of societal problems. My next stop will be with the Neighborhood Coalition for Shelter, a drop-in center on the East Side. Future visits are being planned with Street Works, a program serving many gay, lesbian, and transgender homeless youths, and other agencies that serve the homeless.

I would like to find other analysts who are interested in doing similar outreach work, and would welcome anyone contacting me at 927-4536, or 595-1617. If you prefer, my E-mail address is adfl@columbia.edu.