“I’m not here to give you any advice.” It’s one of the first things Steve Walsh says when he sits down with a client.
Walsh is a psychiatric outreach nurse, and the person he’s talking to is typically homeless or marginally housed and dealing with severe mental health issues, so this statement often comes as a surprise.
“Look, you’re here. You’ve made it through all this stuff we’re about to talk about, so you’ve obviously got lots of strengths. I’m here to listen to you very carefully, add in some questions, and try to get out of you what you think you need. Then I’m going to help you find that,” he says.
Members of The Royal’s Psychiatric Outreach Team are working in dozens of organizations across the city in any given week. They’re working with shelters, drop-ins, community health centres, family resource centres, Indigenous service providers, and social housing. It’s a team of 10, comprised of nurses and social workers, serving the mental health needs of people who are homeless or marginally housed.
Walsh, who has been with The Royal for 25 years, says the key to the Psychiatric Outreach Team's success is its flexibility. Team members must be creative, and sales skills come in handy.
“People don’t want to feel like they’re being evaluated, and many don’t have the insight to know they’re living with mental health issues,” he says. “They’re there to be listened to, and I’m there to hear what they’ve tried, what’s going on in their lives, and what they think they need. If they’re going to take steps towards recovery, we need to get their buy-in.”
"When I’m looking for people, sometimes I stop by where I know people congregate. I’ll keep an eye out when I’m at drop-in centres."
The team sees the individual and can refer them to services – it has access to psychiatrists who can help to clarify a diagnosis, medication, and other treatment options. The team can also provide counselling services and connect individuals with other health services. One of the main goals is to get the person connected with health care and social support systems.
The first challenge, however, is often finding the person in the first place. Many of those the team serves are transient, in and out of shelters and hospitals and other services, and hard to reach by phone. Add mental illness, including addiction, into all this and the challenge the team faces would be daunting to most. That’s where creativity and flexibility come in, Walsh says.
“When I’m looking for people, sometimes I stop by where I know people congregate. I’ll keep an eye out when I’m at drop-in centres,” he says. "Because the team serves many agencies, we are able to collaborate with each other in an attempt to locate and support the person seeking help."
Serving our partner agencies
The Royal’s Psychiatric Outreach Team has two groups of clients. First, there are the individuals themselves – people who are homeless or marginally housed and living with mental illness, including addiction. Also very important, however, are the community agencies the team partners with – agencies doing amazing work, but who don’t always have mental health expertise.
For example, many agencies help people access services – housing, for example. A housing based case manager rarely has specialized mental health training, yet they’re engaging and supporting people with some of the highest needs for mental health support. They may make a referral to the Psychiatric Outreach Team, who will support the individual, but the team can also help support the agencies by providing education, consultation about clients, and connections them with resources to help them support their clients in the future.
Marginally housed vs. homeless
The Psychiatric Outreach Team’s mandate includes helping people who are marginally housed, a term with a broad definition but that can include people at significant risk of becoming homeless, people in houses lacking basic facilities, in rooming houses, or in subsidized housing.
“We’re talking about people who may have a roof over their head but still aren’t having their basic needs met – not having access to the basic social determinants of health,” Walsh says. He shows Caldwell Family Centre, a place he describes as an oasis, as an example of a partner agency serving people who are marginally housed.
Caldwell Family Centre opened in 1986 and continues as a grassroots support in one of Ottawa’s most impoverished communities, where 32 per cent of families are low income – triple the city average.
The centre provides services ranging from meals, a food bank, affordable clothing and household items, educational programming, and access to computers to people living in the area. Almost 150 people eat two meals a day at the centre and also use the food bank, meaning around 70 per cent of their nutrition comes through the centre.
Leaving Caldwell Family Centre, Walsh runs into a client from years ago – someone who was struggling with severe depression and addiction. Now, he has housing in the Caldwell community. “Hello, my friend!” he says to Walsh.
“You look good! Wow, you look strong!” says Walsh, who remembers the man by name.
“You guys did a good job on me!” says the man.
“No, you did a good job,” says Walsh.
Walsh starts his assessments by saying he isn’t there to give advice, and he often ends them with gratitude.
“Often at the end of conversations, I say ‘Thank you for sharing that information with me, because I don’t know that I could have’,” he says. “I don’t want to sugar coat it, but this job gives you so many rewards back. Sometimes the help they need to change their lives is just so minimal, and I consider it a privilege that they allow me to work with them.”
Why research is key for the Psychiatric Outreach Team
In the last decade, the prominence of social determinants of health in discussions of health care has grown exponentially. Research and advocacy fuels these conversations, and The Royal’s Psychiatric Outreach Team has played a significant role in contributing to research on homelessness and mental health in the Canadian context.
“Twenty years ago, you’d basically never hear a doctor ask a patient about housing, about access to food. Now those conversations, alongside ones about mental health, are being introduced in primary care. That doesn’t happen without research and advocacy,” says Susan Farrell, clinical director of The Royal’s Community Mental Health Program, of which the Psychiatric Outreach Team is part.
In addition to amplifying the importance of social determinants of health, research helps improve the Psychiatric Outreach Team’s services on the ground. It helps provide data to understand what’s happening differently in places across the country and some of the reasons why. It helps us understand what homelessness can look like across a person’s lifespan, and how to better help them. It provides Canadian information, which is important because Canadian social services are significantly different from those south of the border.
The Psychiatric Outreach Team published its first paper in 2005 when, after reviewing the available literature on psychiatric outreach, the team realized their model was significantly different from any they had read about.
Shortly after publishing that paper, Farrell became part of a new research group – REACH3 (Research Alliance for Canadian Homelessness, Housing, and Health), a national research group looking at homelessness in the Canadian context. As part of this group and others, Farrell and the Psychiatric Outreach Team have contributed to dozens of publications.
“For housed Canadians, the number one reason we go to hospital is injury; number two is childbirth. For people who are homeless, it’s mental health,” says Farrell.
“We know that health and housing are intricately linked, and now we have a lot of data behind us.”