Office hours don’t necessarily take place within the restrictions of a four-walled room, and that especially rings true for someone like Dr. Yelena Koldobskaya. A psychiatrist based in Los Angeles, Dr. Koldobskaya’s work focuses on street psychiatry outreach to unhoused clients. Her days are typically spent driving around the streets of LA, where her clients are based. With reports that unhoused populations in the city alone reach beyond 75,000, her work is essential and, in conversation with her, looks quite unconventional, and often unpredictable, than other doctors in similar specialties.
Though Dr. Koldobskaya says her career is still young—just six years out of her residency—her path was never directed to this work. Instead, through personal experience and extensive education, she eventually found a career path that’s not only challenging and important but also brings her personal fulfillment. “I take something out of every case that I would then be able to apply to my own life,” she says.
Ahead, Dr. Koldobskaya joins us to share more about the realities of working in mental health, her incredibly unique work days, and advice she’s gleaned along the way.
HOW DID YOU BECOME INTERESTED IN MENTAL HEALTH, AND HOW DID YOU GET INTO YOUR LINE OF WORK?
“My initial entry into the work was kind of nonlinear. I'm an immigrant. I was about 12 when my family came to the U.S. and I had a really hard time adjusting. I always felt sensitive to people who were left out by the system, who didn't quite fit in. Also in college, pretty early on, I had a friend who attempted suicide and that experience was another very significant introduction to mental health.
“I did an undergrad and a Ph.D. in chemistry. And throughout that Ph.D., I was just kind of dabbling and volunteering at the local ER. I was kind of a lost soul at the beginning. I was not super into my Ph.D. I wasn't super into anything. I didn't know what I wanted to do, what I enjoyed.
“During the third year of medical school, you get to experience a selection of basic specialties. I thought I was going to do something like medicine or pathology or just be academically tilted, but I ended up really liking psychiatry. Later, during residency, I started working with the population that I now work with, chronically mentally ill homeless individuals. Eventually, I made the decision to work primarily with that population and leave the research behind.”
WHAT IS STREET-BASED PSYCHIATRIC TREATMENT? WHO ARE YOUR CLIENTS AND WHAT DOES THE WORK ENTAIL?
“It’s a marginalized population that’s all over LA in different situations—in the emergency rooms, hospitals, jail, and on the streets. It's a community that’s very visible here. I think I probably connected a bit, at least in my mind, with the population because I've been so isolated as a child.
“In my work, we find our clients on the street or wherever they're located and try to engage with them on a basic level. We try to bring them food, bring them any supplies they might need, and first and foremost, create a connection. A lot of times these individuals have been so traumatized by the stress of homelessness and by prior life events that they're very on guard, they don't want to engage. And, over the course of these meetings, as a psychiatrist, I'm assessing for any potential symptoms and then start to bring up treatment just very gradually. Sometimes they're open to treatment, sometimes they're not, and we just kind of go from there.”
WHAT DOES A TYPICAL DAY OF WORK LOOK LIKE?
“My team and I have our case list, which comes from a variety of sources in the community. It could be the police, it could be the local businesses, or it could just be that we happen to pass by an area and see somebody who's struggling. Then, we start the engagement process. I start my day with a check-in with the team first thing in the morning—they can bring up anybody that's a concern to them, and I can bring up the people that are currently on my radar and from there we make a list of who we're going to see.
“Afterward we start driving around—always in teams for safety. Sometimes we can't find the individuals on our list. For instance, we'll be driving and see someone's belongings on the street, and can see they were recently there, but the person themselves went to do something else. Sometimes you will see your clients doing other things. They'll be in a shop, on the beach, or sometimes you hear from the local law enforcement that they were arrested or hospitalized. We do our best to track them down wherever they might be. Most of the time we'll see 70-80% of people on the list and then try to do some detective work to find out what's going on with clients we can’t find that day.”
WHAT QUALITIES OR SKILLS DO YOU THINK HAVE BEEN MOST HELPFUL IN YOUR LINE OF WORK?
“It's a very frustrating field. It's challenging. The system is a revolving door and a lot of times you see people get temporarily better and then relapse. In terms of qualities, watching and listening is important. The clients that we see are experiencing a reality that's very different from our own. And for me, what's been helpful is just to be able to hear what they're saying and meet the clients where they happen to be.
“For instance, sometimes it's just not safe for them to go indoors. A lot of times it's not safe for them to fall asleep at night. Sometimes they will pick a particular location, like a storefront or a landmark because they think that they're in the middle of some sort of detective or CIA work or they believe they’re protecting the property or doing something that they think has a big impact. Occasionally they just want to be by the ocean. And one thing I had to learn very early on is that if you come in and you're offering what you think makes sense—staying within four walls and a roof, sleeping on a bed, eating three meals a day—that's not what makes sense to all of our clients. It’s important to get to know where our clients are, where they’re coming from, and what their logic is. We have to align with each person in order to start to help them.”
"One thing I had to learn very early on is that if you come in and you're offering what you think makes sense—staying within four walls and a roof, sleeping on a bed, eating three meals a day—that's not what is normal for everybody."
WHAT DO YOU WISH MORE PEOPLE UNDERSTOOD ABOUT MENTAL HEALTH, ESPECIALLY AMONG THOSE WHO ARE UNHOUSED?
“To start with, homelessness is not a choice. There is a lot of love in the United States for personal responsibility and the idea that you are responsible for where you end up. The events that land people on a street corner, or the sidewalk, are often out of their control. And it might be something like mental illness, it might be the loss of a job or a death in the family. None of that is something that realistically people can fully control.
“The other thing is that their reality and their experience living outside leads to very different perceptions of what's okay, what's not okay. For instance, I've seen people that were just placed indoors with all of the untreated symptoms of their mental illness and they would refuse to use the bed. They would instead create a homeless encampment next to the bed and the bed would be untouched, which just tells you that you're taking somebody with a very different mindset and putting them into what you think is the accepted convention for how people live. And they might not be able to use those resources in the way that one of us might use them.”
WHAT DOES YOUR LINE OF WORK NEED THE MOST RIGHT NOW?
“We need everything. Beds, therapeutic beds, we need housing, we need more treatment teams, more outreach teams. We just absolutely need everything. But this is not a situation that could be resolved by providing showers, bathrooms, and cellphone charging stations. Those resources are not going to resolve the symptoms and traumatizing experiences that some of these individuals are having. It's not going to resolve how unsafe they feel going to sleep at night. So it has to be an all-around kind of approach.”
WHAT IS IMPORTANT FOR ANYONE TO KNOW WHO MAY WANT TO ENTER THIS FIELD?
“What my previous work in a jail and my current work have in common is they're both not office jobs. They’re experience jobs, and you're not just sitting at a desk indoors. You get to see the human condition in a way that most people are not accustomed to seeing, which can be really difficult. A lot of times, people don’t want to hear about what I see day to day—it’s just too unusual, graphic, and frightening. For my job in particular, you can't really have an expectation as to how your day is going to go. So I think my advice is just to be open to experiences and adventures.
“Everyone's story is so unique and special. Sometimes you see improvement with treatment—it's super rewarding when you see somebody get better on medication or you see somebody suddenly accept housing. Sometimes it can take months of treatment and engagement before someone is ready to go indoors. Eventually, they might be able to take another step toward what resembles the conventional four-walls-and-a-roof lifestyle. A lot of times, once our clients start to respond to treatment, we can help them to reconnect with their families. Sometimes we see pretty amazing family reunions where parents and siblings haven’t seen the client for years or even decades. It’s the best feeling in the world to be able to help make that happen.”
WHAT’S A PIECE OF ADVICE YOU WISH YOU HAD RECEIVED AT THE START OF YOUR CAREER?
“I hear from friends who are concerned parents and they think their kid doesn't know what they want to do in their life. And I was that lost soul, too, just floating through a Ph.D. with no purpose, and I ended up doing something that very much has a purpose. You'll find your place. So whether it's family pressuring you or your own anxiety about, ‘Where am I going to end up? What is all this going to look like?’ It's going to be okay.”
Illustrations by Bijou Karman
