In Plain Sight, Out of Mind: Health and Humanity for the Unhoused
Q&A with Dr. Katherine Koh and Michael Jellison (Part 2)
Dr. Katherine Koh is a practicing psychiatrist at the Boston Health Care for the Homeless Program (BHCHP) and Massachusetts General Hospital (MGH). She is also an Assistant Professor of Psychiatry at Harvard Medical School. As a member of the street team at BHCHP, Dr. Koh focuses her clinical care on homeless patients who live on the street through a combination of street outreach, clinic sessions, and home visits for patients recently or unstably housed. She also maintains a general outpatient practice at MGH and conducts research on mental health and homelessness. Her primary interest is improving systems of mental health care for homeless patients. She is a graduate of the MGH/McLean Psychiatry Residency Program, where she served as MGH Chief Resident as well as Chief Resident for Community Psychiatry. She earned her medical degree from Harvard Medical School. She received a Master of Science in Evidence-Based Social Intervention, with Distinction, from Oxford University. She earned her BA, magna cum laude with Highest Honors in Psychology, from Harvard College.
Michael Jellison brings over two decades of dedicated experience to the complex landscape of homelessness, having worked across shelters, clinics, and street outreach for 24 years. As a recovery coach on the street team at Boston Health Care for the Homeless Program (BHCHP), Michael focuses on building trust between the unhoused and those providing medical and social services. This extensive professional background is uniquely amplified by Michael’s own profound lived experience, having lived on the streets and in and out of treatment centers while struggling with self-medication. This unique perspective provides an exceptional and deeply empathetic approach to addressing the needs of those experiencing homelessness. Michael Jellison is a Navy veteran with eight years of service. He obtained a GED while in the Navy, and a degree from UMass Amherst in Counselling and Human Services.
Imagine a city where 771,000 people are without a home on any given night. Many live unsheltered, facing the harsh realities of the streets. This isn't just a statistic; it's a profound human crisis affecting our neighbors. Consider these stark truths: Black Americans, 12% of the U.S. population, make up 32% of the unhoused, while Hispanics, 19% of the population, account for 24%. For those experiencing homelessness, life expectancy plummets to 53 years, compared to 78 for the general population. Why is this happening? Several factors, including the expiration of pandemic-era support, stagnant wages against soaring housing costs, and a rise in migrant populations, are fueling this crisis. Beyond the numbers lies immense suffering – individuals grappling with physical and mental health challenges, substance use, and the enduring trauma of street life. While society often encourages us to look away, there is hope: dedicated “street teams” of physicians, nurses, social workers, and peer counselors who build trust and embark on a "long walk" with individuals until they can access care and find stability. But one vital member of this team is missing: us.
Martin H. Goldstein: Dr. Koh welcome back to continue this important dialogue with the Harvard ALI Social Impact Review. I also want to thank Michael Jellison for joining us. Your lived experience with homelessness and addiction, combined with your 24 years of work in the field – across shelters, clinics, street outreach, and systems-level initiatives – brings an irreplaceable perspective to this conversation. Your voice is critical, and we're honored to have you with us.
Dr. Koh when we last spoke almost two years ago, the number of people experiencing homelessness was 580,000. Today that number is 771,000. Black Americans are 12% of the U.S. population but represent 32% of the unhoused. Hispanics are 19% of the U.S. population but make up 24% of the unhoused. Among sheltered individuals, 25% do not have a high school diploma.
The picture is dark. As a street psychiatrist, what have you seen working in the field with the unhoused – how has that changed over the last two years?
Dr. Katherine Koh: You're absolutely right – the data suggests that homelessness continues to increase nationally, reaching its highest recorded level in 2024. This is thought to be due to a number of factors including the end of pandemic-era policies supporting people in need, increasingly unaffordable housing with stagnant wages, and the growing number of migrants. The increase in natural disasters is another underappreciated contributor to rising homelessness. It’s often not a recognized factor, but more people are being displaced by natural disasters without a system to return them to stable housing.
That’s the picture nationally. On the streets in Boston, we continue to work as a team caring for people who live unsheltered. Changing city policies have resulted in fluctuations in where our patients stay and where we interact with them. In 2024, we opened a new, full-time clinic at MGH for patients experiencing homelessness, which has increased our capacity to care for patients. We continue to see a great deal of suffering – people struggling with physical, mental, and substance use issues, while battling the scars of both early life trauma and the brutality of living on the street – and also breathtaking resilience. Our core mission remains in striving to walk with and care for people experiencing unsheltered homelessness. The work continues to be meaningful, fascinating, and heartbreaking.
Mike Jellison, a member of our team is our extraordinary recovery coach. He has a gift in being able to connect with patients and understand their struggles in a way that I, without that lived experience of homelessness, never could. I am so glad he is here with us today.
Goldstein: I’d like to bring Michael into the conversation. Michael, please tell us about your journey – from the challenging times in your life to being able to work for 24 years in service of unhoused people.
Michael Jellison: Sure. Thank you. I grew up in a broken family. I didn’t know my dad – he left when I was two. My mom raised us, but I started getting into trouble and joined the military. I served in the U.S. Navy for eight years and did well there.
A lot happened during my service that didn’t affect me at the time. When I got out and tried to transition into civilian life, I struggled. I was an engineer, had a license and a good job. But I started drinking. My marriage fell apart, and one thing led to another, and I ended up on the streets. I was in and out of treatment centers and psychiatric wards, struggling with self-medication. Eventually, I ended up in the VA system. Someone suggested I try a 21-day PTSD program. After that I went to a shelter, and then to a residential program for veterans. I stayed there for a year. While in the residential program, I worked on resolving outstanding warrants, addressing past-due child support, getting my driver's license back, and finding employment. I started clearing things up. But when I was about to leave, I was terrified to get my own place, even after a year in recovery. I’d gone through therapy, which helped a lot with PTSD. Then, as I call it now, by the grace of God, the house manager left, and they asked me to stay on. That’s how I got into the field treating addiction and homelessness. I stayed there for another year.
Someone suggested I try going back to school. I’d dropped out in 9th grade and later got my GED in the Navy. I was planning to sign up for a full course load, but my sponsor said, “Why don’t you just try one class?” So, I did, and I got a 4.0. That gave me the confidence to go back and finish a degree at UMass Amherst in Counselling and Human Services.
I got licensed and began working in the field. I started at an emergency shelter, then moved to a detox center as a counsellor. From there, I went to Pine Street Inn, a large homeless organization and then to Mass General and Boston Health Care for the Homeless Program (BHCHP). The last detox I went to in Worcester – I returned there five years later to work. That felt like a full-circle moment. It was heartwarming.
I got my family back – my children, the rest of my family. I cleared everything up. I've now been on the street team for almost 10 years. That’s the longest job I’ve held – even longer than the Navy. I wouldn’t leave it. I’ve found my spot.
Goldstein: Thank you for sharing your inspiring story. You discussed that coming out of the Navy was a challenging transition. Could you speak about that?
Jellison: The Navy provided job education and training. I was an engineer, but they didn’t help me prepare for civilian life. I had to figure that out on my own. While I was in the military, housing and/or funds were provided. My family moved to Rhode Island while I was stationed in South Carolina. There was no support for my family. I wasn’t doing well, got into trouble and I had a record. I wasn’t given any counselling or exit support for recovery. There weren’t any peer programs. Back then, I didn’t even know I had PTSD. Nobody prepared me for the transition to civilian life. It was difficult. I didn’t know how to use a check book, open a bank account, balance a budget, or pay bills. I was overseas a lot, and my wife – who’s passed – handled all of that. I didn’t have any support.
The chaos in my head increased. I started self-medicating even more. It wasn’t until I went through the PTSD program that I began gaining insight. After that, I did a year of therapy with a therapist who really helped me.
Goldstein: Given that you didn’t have a peer and weren’t prepared for the transition, is that something that could be built into programs to help others such as veterans and people transitioning from prison?
Jellison: Absolutely. Peer and community support are two of the most important elements for anyone in recovery or coming from an unsheltered situation. It’s about tailoring that support to the environment. For veterans, for example, having another vet to talk to is huge. Coming out of prison, the same applies – people relate better to others with similar lived experience. On the street, it's the same – recovery peers make all the difference. It reduces stigma and discrimination. There’s no hierarchy. We’re not widening the gap between “us” and “them”. We’re closing it.
Koh: There are some programs, but certainly not at the scale we need. The RISE program (Reentry Initiatives for Support and Empowerment) at program at BHCHP for instance, supports people coming out of carceral settings, includes peers. I have also worked as part of a research group through the VA that created a transition program for soldiers transitioning from the army to civilian life that included a peer specialist. So, yes, some transition programs exist, but they don’t always include peers, and they’re not widespread.
Jellison: We do have some recovery coaches going into jails. We also have someone working with women who have experienced trafficking and violence. But it’s not enough. What exists now is scattered. One organization may have support programs, but they lack peers and have to outsource to other places. We like to keep continuity of care within the organization.
Goldstein: How can we – born into the opposite of homelessness – with access to health care, education, a safe neighborhood, and supportive families walk by and ignore people living in abject poverty in the shadows of robust and thriving cities? How is it possible that we fail to fashion a solution and that these individuals die invisible deaths, as you refer to them?
Koh: Unfortunately, society has socialized us to do that. People are told misinformation about homelessness that is absorbed over time. But it doesn’t have to be this way. For instance, there's a powerful book by Kevin Adler called When We Walk By. He did an experiment with people experiencing homelessness where they wore GoPro cameras to observe how passersby interacted with them. One fascinating takeaway was that children wanted to engage when they walked by the people who were homeless. The children asked their parents to stop and talk to the people on the street, but the parents told them to keep moving. That was sobering and moving. It suggests that we do care innately. Children are curious and compassionate about these fellow human beings but over time, society teaches us to disengage and to ignore the unhoused people in our cities.
However, when you talk with someone unhoused, you often see that the opposite of those misconceptions is often true. These are people just like you and me who have been dealt an incredibly difficult set of life circumstances. Despite coming from a seemingly different world, I find the connection easy – and beautiful. It's easy to find points of commonality, things to talk about, moments of beauty or inspiration. I wish more people could take that step. It’s not that people are poorly intentioned – they’ve just been socialized to walk by. But if they took the time, I think they’d see these are people with struggles, hopes, and dreams like the rest of us.
Matt Nathan: Unfortunately, some believe that unhoused people are resigned to their situation and shun help. They feel others are clueless to their issues. I’ve seen this in other contexts. When you tell someone who’s lost a limb they will walk again, they say, “You have two good legs – how would you know?” So, we started bringing in people with two prosthetic legs who could say, “I’ve been where you are and trust me you will.” What techniques would you recommend to people who haven’t been in your shoes but want to help others take that first step toward healing?
Jellison: There are a few key things. First, you’ve got to have a peer – someone like the person with prosthetic legs in your example. Second, don’t go out with an agenda. Don’t assume you know what’s good for them. Don’t ask questions that lead to empty promises you can’t deliver. The key is trust. Take what I call “the long walk.” Begin with just saying hi. One week they might not talk to you. The next week you might get a sentence. Three weeks later, maybe a paragraph. Six months later, they’re coming to the clinic. No agenda. Just connection. I often say, “How are you doing today? How can we support you?” That opens the door. They’ll tell you what they need – whether it’s a ride, clothes, or help getting somewhere.
Koh: The “long walk” is a term Mike taught me and has become one of my guiding principles. You have to think in terms of months and years, not days and weeks. Eileen Reilly, a senior psychiatrist on our team, also says when she meets a patient who declines to engage, she tells herself, “They’re on the five-year plan.” I think that’s a beautiful mindset. It’s very different from what I was taught in medical training – where you’re expected to make a 30-minute history and come up with a diagnosis and treatment plan on the spot.
With our patients, I often don’t even get to clinical mental health questions until months have passed. Many are severely traumatized. Some have had negative experiences with the healthcare system. Some have psychosis, a disconnect from reality, and don’t even realize they’re sick. If I ask, “When’s the last time you had mental health care?” – that question alone, if asked too soon, can shut the conversation down. It’s so much more effective to listen first, to notice what lights them up. What brings joy? What do they need right now? That’s how we affirm their humanity and build a path forward.
Jellison: Exactly. You can’t go in saying, “Let’s do this,” because they might be thinking about how they’ll eat today or where they’ll sleep. Are they going to be safe tonight? That’s what’s on their minds – basic survival.
Goldstein: You’ve mentioned food, shelter, clothing, and healthcare. Can peer support be a standalone or must it be integrated?
Jellison: I couldn’t do this job without my street team colleagues. I rely on them for support. I can meet someone peer-to-peer, but I can’t do it all. When I’m out with Dr. Koh or Dr. Munson, I don’t wear my badge because I’m a peer. But I want them to wear theirs because it sends a powerful message. I can say, “I work with them. I trust them.” I can bridge that trust with the people we serve. I tell them, “I wouldn’t work with this team if I didn’t believe in them.” Peer support works best as part of a multidisciplinary team – no doubt about it.
Koh: Because of Mike’s lived experience and his gift for building relationships, he’s often the first to make contact. He links patients to members of our team – case managers, nurses, physicians. That’s what enables us to provide clinical care down the road. It reduces the barriers, opens the door to deeper engagement, and makes everything we do more effective.
Nathan: With recovery programs like AA, the idea is you can’t help someone until they want to help themselves. That’s what you both have been talking about – earning trust and listening before acting. Michael, in your case it seems shelters helped “flip the switch” and was pivotal in recovery. So how optimistic are you that unhoused people can reach that point too?
Koh: Yes, we’ve had success stories, which give us tremendous hope. There are people we’ve tried to engage for literally years – and one day they walk into our clinic, or they’re psychiatrically hospitalized, and then they get on medication, gain insight into their illness, and stabilize.
Of course, there are others who have been on the street for years and remain there. That’s heartbreaking. But the success stories remind us not to give up. Your question – what flips the switch? – is important. I’d ideally love to study that more formally, understand what actually creates change, and which engagement techniques are most effective.
But maybe part of the beauty is that we don’t know when someone will take the next step. That’s why we keep showing up, even when it’s hard. We’ve seen people who, when we least expected it, stepped forward – and now they’re stably housed, sober, and coming to our clinic.
Jellison: Yes, we have success stories – at different levels. For someone coming from the streets, just maintaining housing for three years, despite still drinking, is a success. I don’t think there’s a toggle switch. It’s more like a long drive uphill. And every time you meet with someone, you have to treat it like it’s the first time you met them. That helps you stay open, even when progress feels slow.
We don’t always know what will work. One recovery path might not work, so we pivot to another – then another. You keep walking with them and let them drive the process. You stay alongside them.
Goldstein and Nathan: Housing First is often described as an essential first step. But is “affordable housing” the right idea for people on the street without a job and without income? Transitional housing is frequently discussed but many unhoused people avoid it. They feel it’s unsafe or stigmatizing. How is “affordable” understood in the context of homelessness?
Jellison: It’s not just about housing. You need services that support stabilization. When I got off the street, after about a year, I needed more – I needed work, school, purpose. I needed community. So yes, build housing, but build it with community in mind. Create space for a barbershop, a bakery, a shoeshine – let folks work there and provide those services to the neighborhood. That gives people purpose. Providers could meet their participants where they are. This model exists in New Zealand. It gets people off public assistance, back into the workforce, and the community begins to see them as people with beautiful stories. It’s not just housing – it’s support, services, and community. If you place someone in a single-room occupancy ten miles from the community they’ve known for years, it rarely works.
Koh: I completely agree. I’ve been so struck by the way people struggle when moving into housing without the right support. These include issues like loneliness, lack of sense of purpose, or difficulty transitioning to a whole new routine. Putting people in a house without sufficient support is a recipe for failure. We need individualized housing plans the same way we use individualized psychiatric treatment plans. But too often, we just place people wherever there’s an opening and call it done.
Goldstein: Didn’t you once say something like, “One size fits none”?
Koh: Yes, exactly. One size fits none.
Goldstein: You’ve indicated we need to listen better – to understand unhoused people’s needs. For instance, imposing a sobriety requirement before giving someone housing – does that make sense?
Jellison: I think that’s a terrible idea. I didn’t have to do that when I signed my lease – why should they? We’re trying to stop treating the unhoused differently. I’ve seen people handed a long list of rules and guidelines – restrictions like “no visitors after 10 p.m.” or “guests can only stay three days.” That’s not how any of us live. It’s unreasonable. What it should say is: “Hey, we know you’re struggling with substance use – let us know if you’d like support.” That’s the right message.
Koh: And that’s what the data shows. Housing First – the idea of giving people housing before sobriety – increases housing retention. With the right support, housing helps them engage in treatment and stabilize them. The alternative takes longer, has worse outcomes, and doesn’t support people as effectively.
Goldstein: So how do you address substance use in housing if stopping is not a requirement?
Jellison: I’ll speak to the addiction side first. I’ve always had a five-point plan:
Go back to 30-day detox programs – we’ve cut them down to 3-7 days, which isn’t enough.
Every hospital should have a detox and treatment wing.
Better access to medication-assisted treatment.
Hire more people with lived experience.
Increase the number of treatment beds.
We’ve got the foundation – we just need the resources and funding to scale it. That would change a lot. Housing takes time. If someone wants to be housed but is struggling with substance use, we use that as motivation. It’s like a carrot – but softly delivered. I always say, “hit ‘em with a feathered hammer.”
While they’re waiting for housing – gathering documents, going to appointments - we say, “Can you drink a little less so you don’t miss appointments?” Or, “Would you like to stay somewhere safe like McInnis House or go into treatment while we wait? “We’re supporting them, not judging them. And we’re helping them succeed in the process of becoming housed.
But you have to offer customized treatment a la carte. We’ve got buprenorphine, methadone, Sublocade, Vivitrol, mental health treatment – you can weave that into the housing process. For example, say, “Great! You’re going to get your own place like you’ve wanted.” And while you’re working toward that housing, you can start addressing some of those other things. You don’t get dropped into housing in a week. It takes a few months. So, you have time to use it as an incentive to work on yourself and stabilize a bit. We send people to McInnis House, we send them into treatment while they’re waiting to match. There are ways to do it – subtly, gently - even without them realizing it.
Nathan: Please speak to the causes of homelessness as there’s a perception that a major cause is mental illness, schizophrenia, or they’ve had a breakdown and are beyond help. What should we understand about the cause and effect of homelessness?
Jellison: From my 10 years on the streets, in and out of treatment, I’d say the number of people with severe mental illness like schizophrenia isn’t as high as people think. There are people with more common mental health issues, such as depression, anxiety – maybe some schizophrenia. And when people walk by, they assume “brown bag, long coat, schizophrenic” – and think it's all about moral failure. But honestly, some of the best, most caring, most beautiful people I’ve ever met were people on the streets.
We’re lucky to be allowed into their lives to hear their stories, the stories no one else wants to hear. And even among those with severe mental illness, we’ve had success. The street team is doing incredible things. If I had a street team visit me when I was on the street, I probably wouldn’t have suffered for as long and as much. We need more teams, more primary care doctors, more psychiatrists out there on the ground.
Nathan and Goldstein: We carry the assumption that it’s some genetic or mental illness barrier that separates “us” from “them.” Michael, your journey makes clear that homelessness can happen to anyone confronting life’s challenges. Small gestures – a kind word, “hello,” a smile, eye contact – can develop connection and restore dignity. This interview calls on all of us to rethink how we engage with those experiencing homelessness; to move from pity or indifference to empathy, listening, and action; supporting policies, services, and personal behavior that recognize the shared humanity we all possess. So how do we change that perception? How do we change the way people think about and interact with the unhoused?
Jellison: I would say that within society we should try to normalize their struggles when they are on the streets, in hospitals, in stores, and restaurants. It shouldn’t be an us and them dynamic. Address the stigma and discrimination, ensure we are using human experience language. Address malignant narratives in our medical record systems, and community media, all that rhetoric that reinforces the historical portrait of unsheltered folks. Having less pedestrian apathy when walking by an unsheltered person.
Koh: I love the question. First, I wish policymakers and people in power would spend time with people experiencing homelessness. Just one conversation would challenge so many of their misconceptions. These are some of the most resilient, inspiring people I’ve ever met. Too many decisions are made by people who’ve never even spoken to someone unhoused. And if we want to ignite their intrinsic motivation to act, they need that direct connection – the same inspiration we get daily.
Second, we need to address early life trauma. So many of our patients have experienced profound trauma in childhood – being locked in closets, witnessing violence, losing parents. That level of trauma, untreated, makes functioning as an adult incredibly hard. There are parenting support programs like Triple P that help prevent abuse and neglect. If we could support at-risk families early on, we could stem the flow of future homelessness.
I’ve studied soldiers who were separated or deactivated from service and found that lifetime histories of depression, trauma of having a loved one murdered, and post-traumatic stress disorder were strong predictors of homelessness. Homelessness is multifaceted. We must focus on prevention, not just managing those who are already unhoused. That’s the only way to really make a lasting difference.
Jellison: Adverse Childhood Experiences (ACE) is a key upstream problem. We've been trying to find solutions for homelessness for a long time and the numbers keep getting worse for various reasons.
So clearly, we’re not doing something right. It’s an upstream issue – lack of education, lack of stable family structures, poor transitions for veterans or prisoners returning to civilian life. That’s what we need to be looking at. Right now, we’re putting Band-Aids on downstream problems. But if we start upstream, maybe we won’t have this problem 20 years down the road.
Koh: Even if we housed everyone experiencing homelessness today, that wouldn’t solve the problem because of the people coming down the pipeline. Prevention has to be the bedrock of any sustainable solution. There’s early life trauma, but also lack of access to mental health care, education, racial inequities – the homelessness crisis touches every aspect of society. This issue is complex. But that’s why we need people who care.
Thank you for taking the time to highlight this issue, and for having the humility to want to learn more about it. We appreciate that deeply. So much of this is about raising awareness among people who haven’t had the privilege of direct experience on the ground. We’re very grateful to you both – there is much to be done.
Goldstein: This has been a privilege for Matt and me. Thank you both for all you do every day.
About the Authors:
Martin H. Goldstein is a 2020 Harvard ALI Fellow and Managing Editor for the Social Impact Review. Martin has thirty plus years in biopharma, initially at Hoffmann-La Roche, followed by Genentech. Subsequently, as the founder and CEO of ViroLogic, Inc., a clinical laboratory guiding therapy of HIV-infected patients. More recently, he has been working with venture to build biotech companies pursuing cutting-edge science to develop therapeutics to treat disease.
Matthew Nathan, M.D., is a 2020 Harvard ALI Fellow and Senior Editor for the Social Impact Review. Matt was previously the 37th Surgeon General of the Navy and most recently a Senior Vice President for a large tertiary care healthcare system.
This Q&A has been edited for length and clarity.