Emergency psychiatric intervention on the street.

The development of outreach approaches to engage and provide services to the homeless mentally ill must account for the heterogeneity of the population. The homeless mentally ill as a group are symbols of the failure of a comprehensive and integrated system of community-based care to develop in conjunction with the widespread proliferation of deinstitutionalization policies over the past several decades. Life in a community is far more complex and less easily controlled than life in an institution. People are free to reject the label of patient and refuse all mental health services. An engagement strategy must therefore be devised from the knowledge of specific aspects of a person's life in that community, so that outreach and networking efforts can be sensitive to the total context of the problems experienced by that patient. A multidisciplinary team approach is essential to the effort to engage and monitor those chronically mentally ill individuals who are at risk for psychiatric and/or medical decompensation. A variety of skills are needed, and team members must be flexible about their roles on the team. The clinician, while maintaining expert psychiatric, diagnostic, and treatment skills, must at the same time be able to adapt to people in their own environments, provide them with necessary social and medical services, and interface with other agencies working with these persons. The work is very labor intensive. It may involve two or more clinicians spending entire days with one patient. During a crisis state, these patients will require even more intensive attention from multiple team members to prevent decompensation and rehospitalization. In conclusion, there is no one intervention style in the work of psychiatric outreach. While the type of intervention offered follows from the mission of the outreach program, all outreach teams must be able to address the totality of needs of people who are fragile and at risk for psychiatric and medical decompensation. Case management services cannot be segregated easily from the task of crisis intervention in the work with the seriously mentally ill. The failure to establish an accessible network of community-based services for those chronically disaffiliated populations of mentally ill gives the outreach team the critical role of brokering any available services needed to support the individual in the community. The flexibility required of the outreach team derives both from the scarcity of community-based resources and the heterogeneity of the population of chronically ill adults who will most need these services.(ABSTRACT TRUNCATED AT 400 WORDS)