Psych- what are my options for working with marginalized populations?

[kaiasunshine]

I haven't been to medical school yet, but of course, being in the process of trying to get there, it's hard not to think about what area of medicine I'd like to work in. Up until now I was thinking of either family medicine or emerg. There are two areas of my life that I'm trying to plan for:

at home- I want to do something meaningful to me, and working with marginalized populations is most important to me. I love the idea of working with homeless populations, at-risk youth, substance abusers and the mentally ill. I volunteer with those populations and I've known since I was young that this is where my interest mainly lies.

away- I've also had a very keen interest in doing international aid work since being a young teenager. I would say this was the original reason I went into health care, and it's definitely become a passion of mine. Working with Doctors Without Borders has always been my dream.


After a lot of thought lately (and a lot of reading), I think I've decided that I want to do something that makes a more lasting impact in the lives of my patients. I want to contribute to lasting change, and try to do more for a positive future, and mental health seems to be the best way for me to do that- I know I absolutely want to work in medicine, but I want to do more than stitch someone up and send him on his way. Saving lives and helping people to survive long enough to make good decisions is obviously hugely important, but helping people to gain the tools they need to live a happier and healthier life is much more up my alley.

Anyway, the question I have, as I know very little about the field of psychiatry and am not sure how to properly search for what I'm looking for, is what kind of opportunities are there out there relating to what I'm interested in? Obviously mental illness is rampant in homeless populations and at-risk youth, but what options are there for psychiatrists to work with these groups? All I know of is the either psych ward at the hospital or your own practice (but with those prices, how can these groups access that kind of service?). Any insight or help would be hugely appreciated! It feels right thinking about going into this specialty, but I really have no idea what's out there.


*I live in Canada and I imagine that some of the the opportunities can be different in the US compared to Canada because of the differences in the way our health care systems are structured, but I have posted this in premed101 and am curious what the people here have to say!

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[surftheiop]

I haven't been to medical school yet, but of course, being in the process of trying to get there, it's hard not to think about what area of medicine I'd like to work in. Up until now I was thinking of either family medicine or emerg. There are two areas of my life that I'm trying to plan for:

at home- I want to do something meaningful to me, and working with marginalized populations is most important to me. I love the idea of working with homeless populations, at-risk youth, substance abusers and the mentally ill. I volunteer with those populations and I've known since I was young that this is where my interest mainly lies.

away- I've also had a very keen interest in doing international aid work since being a young teenager. I would say this was the original reason I went into health care, and it's definitely become a passion of mine. Working with Doctors Without Borders has always been my dream.


After a lot of thought lately (and a lot of reading), I think I've decided that I want to do something that makes a more lasting impact in the lives of my patients. I want to contribute to lasting change, and try to do more for a positive future, and mental health seems to be the best way for me to do that- I know I absolutely want to work in medicine, but I want to do more than stitch someone up and send him on his way. Saving lives and helping people to survive long enough to make good decisions is obviously hugely important, but helping people to gain the tools they need to live a happier and healthier life is much more up my alley.

Anyway, the question I have, as I know very little about the field of psychiatry and am not sure how to properly search for what I'm looking for, is what kind of opportunities are there out there relating to what I'm interested in? Obviously mental illness is rampant in homeless populations and at-risk youth, but what options are there for psychiatrists to work with these groups? All I know of is the either psych ward at the hospital or your own practice (but with those prices, how can these groups access that kind of service?). Any insight or help would be hugely appreciated! It feels right thinking about going into this specialty, but I really have no idea what's out there.


*I live in Canada and I imagine that some of the the opportunities can be different in the US compared to Canada because of the differences in the way our health care systems are structured, but I have posted this in premed101 and am curious what the people here have to say!

Psych might not be the greatest field for international medicine given the issues of language/culture and need for continuity, but I could be wrong about that. Although more importantly, I think most people interested in international medicine end up having the pressure of home (family, SO, bills, etc) taking priority and they never end up doing as much international stuff in the end, so it might not be best to let international interests drive your specialty choice unless you know your going to be super committed to that.
On the other hand, psych probably is one of the fields that most focuses on helping under-served people in general practice.

In a way, pretty much all psych patients are "marginalized" given the general lack of societal care for mental health. If your doing inpatient, a large percent of your patients are going to be homeless or nearly homeless (its hard to hold a job/family if your sick enough to need inpatient psych). If you want to work with super in need populations, prisons and rural communities are probably in dire need of psychiatrists

 

[kugel]

It seems I have a kindred spirit.

There are such opportunities, but they are relatively rare and sometimes fleeting. The agencies change funding streams and politics always trumps policy. I've been hired by two different counties with the specific goal of providing homeless outreach and mobile crisis, only to have both counties fail to make one move to create them. There are agencies that provide 1 or 2 types of such services, but these are often small non-profit agencies contracted to larger gov't agencies, making funding limited and renewed year-to-year. The VA has some such opportunities in some areas of the country, and I believe community pressures will push the VA to provide more services designed for the homeless vets.

One place you can intervene with marginalized populations is county jail and juvenile hall. Lots of people with mental illness are brought to jail, especially the same sub-cultures who are least likely to voluntarily go to mental health services.

Most agencies don't see the cost-effectiveness of paying a psychiatrist to go out into the streets. The bureaucrats generally see the value of psychiatrists in "how many pt's seen per hour," even if 80% of those are minor fiddling with an existing regimen. They do not see the value of having a full-fledged provider initiating treatment where the patient is (geographically and mentally). They do not see the value of having a provider meeting the patient in his own reality and trying to find a way for psychiatric treatment to assist him with the real stresses in his life, taking account of his difficulties in finding water, bathrooms, hygiene, and weather. And that having a bottle of medicines makes him a target for getting mugged. That provider, then, can establish trust and begin introducing the patient to the services available at those big scary government offices. Appointments and hygiene and bus schedules are just not part of his world yet. But we can get there with an understanding of His world and his timeline.

In most of these agencies, it is not even the physicians who decide which patients gets into psychiatric services. A social worker or therapist decides who qualifies and who needs meds - so the psychiatrist only gets to see those vetted by non-physicians. I get sent a lot of people who scream that, "I have to have my meds! You don't understand that I can't sleep without my meds and I beat the crap out of people when I don't have my meds. Plus, my parole officer says I have to have a place to live and my Mom won't let me continue to live at home unless I'm on meds, so if I don't get my Seroquel, you are causing me to go back to prison. Do you understand that?" Such patients are largely substance abusing personality disorders and, as such, least likely to actually benefit from meds and most in need of rehab and therapy services.

 

[nitemagi]

Agree with above. I lucked into a gig right now where I'm doing outreach as part of a well thought out project. But in general working for your local county hospital and/or clinic will reach those in need. If you do psychotherapy you could also pick up some volunteer/pro bono cases for those that can't afford you.

Internationally DWB does want mental health professionals:
http://www.doctorswithoutborders.org/work/field/profiles.cfm?id=2537
And there's alternatives:
http://www.projects-abroad-pro.org/pro-search/?content=medical/
There's a DWB specific for psychiatrists, but I can't seem to find the link anywhere.

In my searches, I found this too (amusing)
http://rationalwiki.org/wiki/Homeopaths_Without_Borders

 

[kaiasunshine]

Psych might not be the greatest field for international medicine given the issues of language/culture and need for continuity, but I could be wrong about that.

In a way, pretty much all psych patients are "marginalized" given the general lack of societal care for mental health. If your doing inpatient, a large percent of your patients are going to be homeless or nearly homeless (its hard to hold a job/family if your sick enough to need inpatient psych). If you want to work with super in need populations, prisons and rural communities are probably in dire need of psychiatrists

There are a few places in Canada that offer residency electives in cross-cultural and international psychiatry that I was looking at this week that looked really interesting, actually! This kind of thing abroad is definitely a lot less universal than direct, physical medical care, but I think it would be possible with proper training and consideration! You're so right, though, about all psych patients being marginalized. I guess I wasn't thinking of it that way, but it's true that pretty much every person with a mental illness is suffering from stigma and social isolation. I do tend to prefer (from my limited experience) working with homeless and extremely at-risk groups, as opposed to depressed middle-class workers. Not that there is ANYTHING less substantial about the suffering of middle-class people, of course, but I find that I tend to be more attracted to the idea of working with people who are struggling not only with the mental illness, but with many other social and financial struggles. I like your idea of working within the prison system- that's something that never crossed my mind, but the proportion of mentally ill people living within that system compared to non-ill people is pretty massive. That would definitely be something I would consider

It seems I have a kindred spirit.

One place you can intervene with marginalized populations is county jail and juvenile hall. Lots of people with mental illness are brought to jail, especially the same sub-cultures who are least likely to voluntarily go to mental health services.

Most agencies don't see the cost-effectiveness of paying a psychiatrist to go out into the streets. The bureaucrats generally see the value of psychiatrists in "how many pt's seen per hour," even if 80% of those are minor fiddling with an existing regimen. They do not see the value of having a full-fledged provider initiating treatment where the patient is (geographically and mentally). They do not see the value of having a provider meeting the patient in his own reality and trying to find a way for psychiatric treatment to assist him with the real stresses in his life, taking account of his difficulties in finding water, bathrooms, hygiene, and weather. And that having a bottle of medicines makes him a target for getting mugged. That provider, then, can establish trust and begin introducing the patient to the services available at those big scary government offices. Appointments and hygiene and bus schedules are just not part of his world yet. But we can get there with an understanding of His world and his timeline.

I'm so happy to hear from someone with similar ideas! I try not to be unrealistically idealistic, but this is genuinely what I want to do with my life and I think a bit of idealism is the only thing that can help us move forward. Unfortunately, our systems tend to fight with us on trying to achieve these goals, in favor of money and big business. I feel like with universal health care, there might be more opportunities here (most health care is not dependent on the person having a job and insurance coverage), but we deal with so many of the same issues as the US, as resources are not unlimited. Volunteer work would be a definite part of my career plan, but perhaps it'll have to take up more time in order to really make any real difference...

Agree with above. I lucked into a gig right now where I'm doing outreach as part of a well thought out project. But in general working for your local county hospital and/or clinic will reach those in need. If you do psychotherapy you could also pick up some volunteer/pro bono cases for those that can't afford you.

So the programs do exist, it's just a matter of finding them I suppose! Psychotherapy would be a definite focus for me, as much as possible, and it does look like there are plenty of resources out there for psychiatrists to match up to volunteer opportunities!

 

[kaiasunshine]

global mental health is a big thing these days and there are many, many programs that do this in the US and in canada, although few are established - the main one on the US is MGH, and the main one in canada is the university of toronto. However most global mental health work is quite frankly an embarrassment, focussing on exporting western concepts of distress to the rest of the world (especially PTSD) rather than learning about cultural variations of manifestations to trauma and its management. it is a new form of imperialism.

McGill actually has a great program in social and transcultural psychiatry. The importance of mental health care in the developing world is more in service development and training up nurses and others in areas where there are no physicians, let alone psychiatrists. The big psychiatric problems are HIV/AIDS, schizophrenia, mania, catatonia, delirium, and epilepsy (epilepsy is regarded as a neuropsychiatric in many developing countries) NOT PTSD and other western constructs. Obviously cultural and language barriers make it alot more challenging - the most portable specialties for working in the developing world are emergency medicine and OB/GYN. I have spent some time in poor resource settings - very challenging, very frustrating, very depressing, i think i probably cried every day and i never cry! Again the need is much more at the policy level and in health service development so we can improve access to care and the quality of care as well as looking at prevention. Some of the global mental health work has been done with such enthusiasm that people seem to have forgotten that what alot of people need is food, clean water, housing, education for children, and NOT psychiatry.

Very interesting thoughts. I definitely agree that schizophrenia HIV/AIDS-related psychological issues are urgent needs, but could you explain to me a little bit more about what you mean by PTSD not being a psychiatric problem in places other than the west? I'm unclear on this. In my mind, I would expect war-ravaged countries (especially in places like Rwanda where unimaginable violence has occurred in the recent past, or Congo where rape is regularly used as a weapon of war) to have massive numbers of people unable to cope with the extreme loss and violence, and what I would imagine is PTSD. I would think that in places where sons have been forced at gunpoint to rape their own mothers, or where children have lived years of their lives as soldiers and slaves, there would be a huge proportion of the population needing at least a little bit of counseling and psychotherapy? I don't think that anyone's forgotten about the world's need for food and water, but I certainly would not say that psychiatry is at the bottom of the totem pole of needs in these places. For the people who are receiving aid for their physical needs, how are we to expect a hopeful future for these societies when 95% of the adult population (again, using the example of Rwanda) has either violently murdered dozens of people, or witnessed such acts? Can we expect the general population to simply move past these experiences and never be influenced by the traumas?

 

[splik]

why don't you start with this:

 

[kugel]

I wonder if there isn't an adaptive value to many of the PTSD sx's, when you are still in the situation and the threat is still out there. It seems likely that it is a historically new situation that people are able to move out of their immediate environment quickly and completely, and that it is often the inability to adjust quickly to the new "non-threat" situation which is distressing and pathological. Perhaps PTSD numbing, heightened reaction, reaction to only a portion of the stimulus and dissociation are adaptive (permit you to live long enough to distribute your genes) in the situation where you cannot effectively escape your situation, or at least such symptoms prevent you from entering any situation even remotely similar to what almost killed you.

Just spit-balling here. I have no research or facts.

 

[freaker]

If you truly want to work with marginalized populations, skip the homeless population and go rural. There are regions in this country where there is only a single psychiatrist covering a 15-20 county area: that's marginalized.

In my area, there are multiple clinics available to the homeless free of charge in larger cities. But try finding a psychiatrist within several hours drive in those rural communities.

In those populations, you have the depresssed job prospects and all that comes with that there, and you'll have a population that's grateful you're in town, who will try to keep you there, and who will be a little surprised you came to help them and suspicious you'll leave. My experience with rural communities has been much more rewarding than in working with the urban poor, as well, who I have found have a much greater sense of entitlement, in part due to the relatively numerous resources offered to that community. Others' experiences will no doubt vary.

Keep in mind that in working with a prison population, you're going to have a lot of antisocial personality disorder-types. Many of them are not going to give you that warm fuzzy feeling that you get from helping someone out who has been truly marginalized--quite the opposite. Try to keep a good balance in your life. I see tons of Teach for America teachers getting burned out for the same reason, thinking they're going to change the world and frankly losing all hope. It's a tough world out there..

 

[loveoforganic]

If you truly want to work with marginalized populations, skip the homeless population and go rural. There are regions in this country where there is only a single psychiatrist covering a 15-20 county area: that's marginalized.

Oh come on, what's even the point of comparing the two like that. Homeless are so marginalized it's disgusting. Whether or not rural pop is comparable still shouldn't lead to that shrug off of a comparison