Invaluable Clinical Knowledge for Outreach Workers Dealing with Homeless People

An outreach worker dealing with the homeless is surrounded with patients; indeed, there is hardly anyone among the homeless who isn’t afflicted by some relevant medical condition, and there’s no helping them without addressing whatever such issue plagues them. Clinical knowledge may help determine when a client requires a clinical evaluation, and may even save the client’s life.

After spending years volunteering among the homeless, doing my own brand of outreach and advocacy, allow me to share some of my experience by listing symptoms and conditions I’ve encountered, how to recognise them, and what to do about them:

Alcoholism: One easily neglected symptom of alcoholism in susceptible patients is extreme hostility and violence; the patient may try to pick up a fight with anyone in the vicinity, for no reason whatsoever, and stonewalling has no effect. It is debatable whether one should call the police on such people; I would rather try to isolate them first because police officers may shoot them outright. In any case, if they do not quit drinking such alcoholics are likely to end up in prison or dead.

Autism: How to deal with autistic patients is beyond the scope of any article, or arguably even book. That being said, advice on how to deal with introverted people is a good start; introverts tend to fare poorly in group activities and prefer one-on-one engagement, for example.

Borderline Personality Disorder: “I hate you, don’t leave me.” Borderline patients make the worst relationship partners and are extremely challenging to interact with in any context. In a crisis, it may be best to just stonewall them until the outbreak passes.

Brain damage: It is estimated that about half of homeless people have some kind of brain damage. Symptoms can vary tremendously from one patient to another, depending on the area that has been damaged, of course. Memory impairment is arguably the most common manifestation; the patient may need to be told the same thing ad nauseam, to the exasperation of outreach workers. Mood disorders are also common as a result, and their train of thought may appear random. I find it best to avoid arguing with them and let them dictate the flow of the conversation; just be a good listener.

Cannabis use: The two most noticeable symptoms of cannabis overdose are hallucinations and paranoia. The patient may respond to imaginary verbal attacks from a bystander who says and does nothing… and sometimes isn’t even present. Treat them like psychotic patients until it passes.

Delirium Tremens: The clinical term for acute alcohol withdrawal. The most common symptom is hand tremors. In rare cases, it may lead to convulsions and even death.

Dementia: Very common among the elderly, and yet very poorly understood by outreach workers. The most common and obvious symptom isn’t even memory loss, but rather regression: the patient behaves like a three-year-old, and may need to be treated as such instead of being enabled by trying to reason them. Aphasia is also common; the patient may start rambling and eventually forget what they meant to say at the beginning of the sentence. Dealing with such patients is always challenging and requires mountains of patience and empathy.

Diabetes: Usually the patient is more knowledgeable about the condition than the outreach worker (or even health care professional), so the best thing to do is defer to them. Don’t you refuse them food if they complain of low blood sugar. By the way, fruits are terrible at raising glucose levels and contribute to insulin resistance, but fruit juices usually have added sugar so these do a better job. Also, a glucose meter is a cheap and useful addition to a first-aid kit, in case the patient is in shock.

Emotional crisis: People with cognitive or emotional impairment are particularly prone to violent outbursts if they feel frustrated, often over apparently random triggers. The best thing to do then is withdraw and try to be supportive; in contrast, lectures and yelling are most counterproductive.

Hearing impairment: An elderly person who speaks loudly and sounds offensive may simply be unable to hear properly; try ruling that out before resorting to lectures.

Illiteracy: While not technically a clinical condition, it is frequent among the homeless. The illiterate will usually conceal their handicap by reacting in a hostile or evasive manner whenever a task involves reading, and may require being challenged directly in order to address it (or even get them to admit it). Avoid shaming them or confronting them, of course. And remember: they can’t read signs.

Methamphetamine use: One classic symptom is hypersensitivity to sound; the patient may display extreme irritation at a high-pitch noise everyone else struggles to even discern. It’s also common in people working night shifts (and that includes outreach workers), in which case they may look severely sleep-deprived, irritable, hysterical, and of unnaturally pale complexion. Cocaine use’s signs and symptoms largely overlap with that of methamphetamine.

Night blindness: Some people, for medical reasons, cannot see properly in the dark, which may lead to all sorts of hazards, from accidents to scuffles. If staying at an overnight shelter, try to keep them near the entrance.

Nutritional deficiency: It’s common for homeless people with no teeth to have a diet of Rice Krispies with milk, three times a day, for example, while alcoholism is known to worsen the problem (alcoholics may even forget to eat altogether), so watch out for signs of severe nutritional deficiencies, such as night blindness due to vitamin A deficiency.

Orexin deficiency: Orexin is a neuropeptide, and a deficiency can cause various neurological conditions such as schizophrenia. Diabetics are susceptible to it. Notably, one thing that raises orexin levels is nicotine, so these patients may struggle to quit smoking.

Panic attack: Do not underestimate the severity of panic attacks; they can even result in death. A panic attack is nothing like a mere bout of anxiety. The patient behaves as in an actual fight-or-flight scenario, which can cause a heart attack or a stroke in extreme cases, and of course an accident or an act of violence. Restraining the patient may prove impractical and even counterproductive; it’s much better to give the patient their own space and wait it out if possible.

Paraneoplastic Syndrome: Okay, I admit this one is a bit of a mouthful. This is common among cancer patients, whose immune system may start attacking healthy cells similar to the cancer cells, which can mess up with the brain and cause pressure of speech or psychosis. This is something to discuss with their health care provider.

Post-Traumatic Stress Disorder: PTSD patients are prone to phobias, sudden flashbacks, and even violent outbursts which at first glance may be difficult to distinguish from psychotic outbreaks. Fortunately they can usually be reasoned with, unlike psychotic patients, but it’s important to give them their own space instead of lecturing them. Most pertinently, many PTSD patients cannot wear a face mask due to their trauma; they may have been forcefully muffled from behind by an aggressor, for example.

Pressure of speech: This is a psychiatric symptom. Simply put, the patient cannot stop speaking, and is usually hostile or extremely confused. Lectures are obviously counterproductive; if possible, just leave them alone, they’re harmless. If caused by hyperactivity, look for possible food triggers such as salicylates or food colouring.

Psychotic outbreak: Psychosis is a profound disconnect from reality, usually accompanied by extreme confusion and even hallucinations. Do not enable these people with rational arguments, it only makes things worse. To be honest, there is no foolproof way to interact with them, although going with the flow can help; try to exploit the situation with arguments that would not work on a rational person, such as giving them a “jingle stick” that magically silences their voices (not my idea; an outreach worker told me she tried it on someone and it worked). Watch out for megalomania though; if they behave like they might try to stop a ten-wheeler with their bare hands because they’re the reincarnation of The Incredible Hulk, it’s time to call 911. If they look hostile, avoid bursting their bubble and they will most likely ignore you in favour of whatever is inside it.

Schizophrenia: Often the result of, or at least worsened by, drug use (which of course includes smoking tobacco); weaning them off may prove effective. If quitting smoking worsens the condition, see orexin deficiency above.

Serotonin syndrome: Many drugs and medications can raise this neurotransmitter to dangerous levels. The most noticeable symptom is the patient feeling uncomfortably hot for no apparent reason; once infections and hyperthyroidism have been ruled out, serotonin excess becomes probable. This is a potentially life-threatening condition which may require calling 911 in extreme cases.

Sleepwalking: Patients in a sleepwalking episode may attempt to perform arbitrarily complex tasks in that state; in the worst-care scenario they may even commit acts of violence. Wake them up quickly if you can do so safely, otherwise avoid bursting their bubble.

Sociopathy: The most important thing to remember when dealing with sociopaths is never to show them any weakness; if you do, they will take advantage of it. If an argument with them turns into an interrogation and you’re struggling to defend yourself from a barrage of insidious personal attacks, it’s time to stop enabling them and be firm. Ironically, sociopaths tend to respect strength (and other sociopaths, by the way) so don’t hesitate to retaliate by raising your voice and adopting an intimidating stance.

Victim Complex: Very common, especially among visible minorities. When people who feel persecuted are confronted, they may answer by making themselves as big as possible and yelling as loudly as possible (while being as obnoxious as possible, of course); in the wild, some animal species that cannot fight, run, nor hide have developed similar strategies to ward off predators. Stonewalling is counterproductive, as it makes the behaviour even worse and may escalate into a physical altercation. It’s best then to pull out, since they won’t have anyone left to yell at and will shut up on their own. Counselling is effective at correcting such behaviour.