CATR: For those who haven’t encountered it, what is street psychiatry? What are its core principles, and how does it differ from more traditional models of care?
Dr. Lo: I think about street medicine in two parts: 1) what we do and 2) how we do it. The “what” is that we deliver care on the streets to people who are unhoused, and offer mental health resources, addiction resources, and harm reduction tools. Our team consists of psychiatrists, a licensed clinical social worker, a program manager, and a recovery coach. We do outreach five days a week, usually in conjunction with community partners. More important is the “how”—our philosophy. We practice proactive outreach and meet people where they’re at, both literally and figuratively. We go to people in encampments, under bridges, and on street corners. We visit repeatedly over time and show empathy, thereby building trust. That may mean saying hello and being turned away, but then coming back with socks, food, and water, with the hope that the person will eventually feel safe enough to work with us. When they’re ready, we offer everything from psychotherapy to full medication management. It’s a long game built on rapport, and the relationship is the intervention that makes the rest of it possible.

CATR: Why is it important for clinicians to know about street psychiatry?
Dr. Lo: Street psychiatry is a relatively new model of care, so many providers aren’t even aware of what we do. We believe that the skills we practice in the field—harm reduction, nonjudgment, therapeutic rapport-building—are just as useful in clinics and hospitals, so we train a lot of health professionals, students, residents, and fellows. Taking off the “white coat,” reversing the power dynamic, and listening without judgment can allow a provider in any setting to better understand their unhoused patient’s reality. With patience, that can lead to substantive, sometimes lifesaving change. And in our years of doing this, we’ve seen amazing success stories, like people who move into housing after living on the streets for years or even decades. We refuse to give up on people who are considered the most “difficult” patients, who are thought to be incapable of change—and we see them recover and succeed.

CATR: I imagine the patients you serve are shared as well.
Dr. Lo: Many of our patients are the very same people who cycle through EDs and inpatient units. We follow up with those unhoused patients in the community who may be difficult to find or may otherwise be lost to follow-up. We link those patients with our network of social services, which can ideally lead to housing. On the flip side, many of our other patients utilize the hospital very little. In fact, these are often our most vulnerable patients. Partnering with clinics and hospitals to engage these patients is an important opportunity, and working together is essential. Street psychiatry teams can make contact when someone is at a hospital and build upon that relationship after discharge. These are the people who often fall through the cracks, but we can continue engagement and make sure that medications, such as buprenorphine or naloxone, are available during the critical post-discharge period when overdose risk is highest.

CATR: Who tends to be your “typical” patient?
Dr. Lo: Our target population is unsheltered, unhoused people who are living on the street. Though everyone we see has a unique story, many have a diagnosis of a serious mental illness or a substance use disorder (SUD). The most consistent thread I see is trauma—often lifelong trauma that doesn’t fit neatly into a formal PTSD diagnosis. That trauma leads to dysfunction in work and family life, isolation, loss of social supports, often substance use, and eventually homelessness. It also contributes to serious mental illness—mood disorders, significant anxiety, PTSD, and even psychosis. Dual diagnosis is very common. The literature says alcohol use disorder (AUD) is the most common diagnosis among people experiencing homelessness, and that rings true in our experience, but under that there is almost always a story of long-standing trauma—and ongoing trauma that unfortunately continues during homelessness (Gutwinski S et al, PLoS Med 2021;18(8):31003750).

CATR: How do you find people to work with?
Dr. Lo: It varies. Most often it is through direct outreach: We visit places where unhoused people tend to congregate (parks, known encampments, drop-in centers, etc). We try to build relationships with people dealing with mental illness or an SUD and continue targeted outreach to those individuals over time. Other times we receive referrals from our street medicine colleagues or our wide network of outreach and engagement workers who are housing specialists, recovery coaches, and people with lived experience. We also collaborate with our own clinic and hospital system to identify the so-called “high utilizers.” These are patients in and out of the ED and psychiatric hospital, many of whom are unhoused. We try to find alternatives for them and become their safety net, especially when lack of shelter or housing is the root cause. But we also try to identify the “non-utilizers.” These are people who need care, even hospitalization, but stay away for all kinds of reasons: the daily grind of ­survival, fear of judgment, and systemic discrimination of the health care system against unhoused people and those with SUDs. These patients can be more difficult to identify but may be just as vulnerable. 

CATR: I imagine these “non-utilizers” might be challenging to engage.
Dr. Lo: In many cases, yes. With those patients we actively try to reverse the power dynamic by going to them in their space and asking if we can help. If the answer is “no,” that is okay too because we want to show them we respect their autonomy. Sometimes the most important things we do in an encounter are to listen, witness what the person is living through, and validate them. Even if a person is not interested in formal treatment, we can facilitate access to shelter and advocate for housing for those that want it. For many patients, housing itself is the most impactful intervention on their mental health. 

CATR: How widespread is street psychiatry nationally?
Dr. Lo: There’s been a lot of momentum in the last 5–10 years. Some programs have been doing this for decades, sometimes under different names—street medicine with a mental health component, mental health outreach, intensive mobile treatment, versions of assertive community treatment (ACT). ACT differs in that it targets a fixed caseload of high utilizers and doesn’t generally do assertive engagement with new people. The street medicine movement has been a great organizing force for those of us doing the work, and over 150 street mental health providers meet regularly to share best practices and support the growth of street psychiatry. 

CATR: The setting you describe is the opposite of a clinic or inpatient unit. How do you maintain safety for you and for the people you’re serving?
Dr. Lo: First, we go out as a team, never alone. We adopt the mindset that we are guests. We need to be invited into people’s spaces to be respectful and to accomplish anything. We go in with a nonjudgmental frame of mind and accept it if people reject us. That stance is protective; we’re not entering and telling people what to do. We may decide not to approach people who are actively intoxicated, acutely psychotic, or otherwise in crisis. In such higher-risk situations, we may enlist additional supports, such as a mobile crisis team or a local peer and social work team, or return another time. And if the patient is new, we do our best to avoid going in blind by gathering collateral from referring providers, family members, and any prior treatment records that we can obtain. 

CATR: Let’s shift to addiction care. How do you approach treatment when the people you’re seeing have limited access to structured medical settings?
Dr. Lo: We think in terms of readiness for change along a spectrum, and we start with harm reduction. On the most basic level, that’s survival—blankets, socks, and food. We provide condoms. For addiction specifically, it’s naloxone kits, sterile needles, safe smoking kits for crack cocaine, and test strips for fentanyl and xylazine testing. These are lifesaving supplies, but they’re also engagement tools. When I offer someone sterile needles, I’m communicating that I see them without judgment and that I want them to survive. Over time, people may move along that spectrum and decide they’re ready for treatment, which looks different for different people. One thing we’re very proud of is our ability to offer same-day buprenorphine inductions. We do registration, HIPAA consents, treatment consents, releases of information, urine drug screens, full history and physical, vital signs in the field, and scheduling of close follow-up. Currently, we don’t carry a stock of medication with us when we see patients, so we prescribe to a pharmacy for pickup, or we pick up and bring it to them. 

“We think in terms of readiness for change along a spectrum, and we start with harm reduction. These are lifesaving supplies, but they’re also engagement tools. When I offer someone sterile needles, I’m communicating that I see them without judgment and that I want them to survive.”

Emma Lo, MD 

CATR: What protocols do you use to start buprenorphine?
Dr. Lo: We’ve tried the traditional approach—stop using, wait for moderate withdrawal, then start small doses and titrate over a few days. Sometimes that works, but people struggle to wait for adequate withdrawal, and we’ve had cases of precipitated withdrawal likely due to high synthetic opioid prevalence. We have shifted to microinductions starting with 0.5 mg at a time with some success. The newer macrodosing approach is promising since it gets patients quickly up to 24–32 mg in the first 24 hours. We’re looking forward to implementing macrodosing and determining when each induction might be most helpful. (Editor’s note: See CATR April/May/June 2024 for more information about these buprenorphine induction methods.) 

CATR: What about long-acting injectables?
Dr. Lo: We do provide long-acting buprenorphine for our patients, following the same protocols as in a clinic. The difference is that we administer the medication in the field to reduce the barrier of requiring the patient to come in. This is a game-changer for those who struggle to take buprenorphine every day, and it essentially eliminates diversion concerns. So far, we have just switched patients from sublingual to long-acting buprenorphine, but for new patients, the “direct-to-inject” model is promising (www.tinyurl.com/bdfkkwe8). As for extended-release naltrexone, the barrier is the washout period: It’s very hard for people to remain opioid free for 7–10 days. Ideally, people would receive that injection during a hospitalization or in jail before release, and we could coordinate continuation. 

CATR: What about treatment for AUD or benzodiazepines?
Dr. Lo: We offer medications for AUD such as naltrexone and gabapentin, and if desired, we help the patient get to a detoxification or inpatient rehabilitation program through our networks. We don’t generally prescribe benzodiazepines on the street due to difficulty monitoring and concerns for safety and diversion (Editor’s note: See our interview with Dr. Holt on page 6). I should mention that we always advocate for voluntary interventions. Except in certain life-threatening ­circumstances, waiting for the person to be ready for treatment on their own is more successful since we preserve our alliance to be able to work together long term. 

CATR: There’s been an executive order that makes encampment clearings easier (“Ending Crime and Disorder on America’s Streets—The White House,” Executive Order No. 14321, 2025). How does that affect your day-to-day work?
Dr. Lo: Encampment clearings are harmful to patients. Data show associations with increased overdose deaths, hospitalizations, and disconnection from services, including substance use treatment (Barocas JA et al, JAMA 2023;329(17):1478–1486). And there’s no evidence that clearing encampments moves people into housing faster. From a practical standpoint, displacement makes our work harder. Moving people without notice makes them harder to find and disrupts care; for instance, medications and important housing documents are often discarded during these sweeps. I’ve had patients reluctant to go to the hospital, even with life-threatening issues, because they’re afraid their encampment will be cleared while they’re gone. 

CATR: Can you tell us how our readers can learn more about potential street psychiatry services available in their area?
Dr. Lo: The Street Medicine Institute (www.streetmedicine.org) has a wealth of resources about street medicine and street psychiatry. Reaching out there can usually lead you to a local street psychiatrist or mental health clinician if there is one. 

CATR: Funding must be a challenge in getting these programs off the ground.
Dr. Lo: Funding is always a barrier when treating people with limited resources. In our case, we are funded by the state of Connecticut. Other programs are funded by a mix of grants, county mental health, philanthropy, and contracts with nonprofits. We bill if the patient has insurance like Medicaid, but the revenue from billing is limited. We have an emerging group called the Street Mental Health Coalition that can help people develop a program if their city doesn’t yet have one. It’s still in progress, but future updates will be available at https://streetpsych.com. 

CATR: Any final thoughts?
Dr. Lo: The overarching message that I return to time and again is to meet people where they are. That applies to unhoused people, but also to the one sitting in front of you in clinic. If someone who is unhoused makes it to your clinic, they may have woken up without a phone or a clock, gone without a shower, found transportation across town without having eaten, sat in a waiting room while holding it together, and then made it through an entire evaluation. Assume that person has already climbed a mountain to get there. It changes your approach. If a patient is not ready to make huge changes in the first appointment, that’s okay. Offer a path that can be taken in small steps; even a small step can be a victory. And hold the door open when there are setbacks. When someone’s ready, move quickly. That might be same-day buprenorphine, referral to housing assistance, whatever matters to them. Finally, if you have a street team in your area, reach out. We can do a lot together that neither of us can do alone.

CATR: Thank you for your time, Dr. Lo.