Street Psychiatry in Hawaii | Interview with the “Hawaii Street Doctor”

Added: 2026-05-09

[00:00:00]Hello guys. I am currently in Hawaii. I was here for a speaking event and everyone kept telling me about the Hawaii street psychiatrist. And today I'm here with Dr. Koyanagi and I'm here to ask him a little bit about what he does and the work he's doing with not just patients but people who are suffering from homelessness and a lot of the people in the schizophrenia population who aren't able to get the help they need in traditional means. So before we get started I wanted to give you a chance to kind of introduce yourself. Tell my audience a little bit about who you are and how you got started with this mission to help people who might not otherwise be able to get the help they need.

[00:00:38]>> I'm so honored to be here. Thanks for inviting me. I've heard all about you.

[00:00:42]You do great things.

[00:00:43]So my name is Chad Koyanagi. Born and raised in Hawaii, four generation Japanese Okinawan American.

[00:00:51]Went to public school, went to Harvard for college, came back to medical school. As soon as I finished my residency program I residency program in psychiatry. I One of the jobs that fell into my lap was a part-time job in a safe haven in Hawaii.

[00:01:06]It's no longer in existence but a safe haven is a is a housing first place for people with severe mental illness and chronic homelessness. Ever since that time I fell in love with the work and seeing the amount of difficulties these people have and the way that the mental health system fails them over and over again. Also seeing the incredible passion and dedication some of the homeless outreach workers have.

[00:01:29]They're some of the most intentional and compassionate people I've ever met. So ever since that time like 26 years ago when I finished my residency just falling in love with doing the work and just finding people who have fallen between the cracks of mental health systems problems and dedicated my life to um being a street psychiatrist. I'm the only one in Hawaii who goes out to the streets regularly. And so it really opens my eyes to all the all the ways that the mental health system can get better and I do my best to try to get people build engaged in first, then get them treatment, get them housing, get them medical care and then some of the other stuff that comes later.

[00:02:06]>> And so I saw the documentary that was done called an island of the mind where they were able to follow you and kind of see how you are able to help people who otherwise like you said are are missed through the the system. And so as someone who's been diagnosed with schizophrenia I think one of the things I was very privileged to have was family support and access to insurance and medication. And a lot of people I didn't realize until I started doing schizophrenia advocacy don't have those things. And unfortunately uh although people with schizophrenia make up less than 1% of the population, the last study I saw said we make up over 20% of the homelessness rate.

[00:02:46]And and it seems like you've been able to to really reach out to those people.

[00:02:50]So my my first question for you is what do you think is the hardest part of working with this population? Cuz I know as someone who's been a patient and had such a lack of awareness I wasn't always an easy person to deal with. So what do you think are some of the biggest struggles in dealing with this population especially those struggling with homelessness? So this population one of the gentlemen portrayed in this documentary is a guy named Ainoa. He's probably been on the streets for like 20 or 30 consecutive years without treatment.

[00:03:20]Um So he he he he illustrates some of the difficulties that we have with with this kind of work usually because of the extent of these people being untreated for so long.

[00:03:33]Psychosis is quite severe.

[00:03:36]For for the number of years that I've known him on the streets he was always very hostile. Wouldn't wouldn't engage with us. Would just start yelling at us, throwing stuff at us, running away.

[00:03:49]So it took a while for us to try to get to know him a little bit better. It was a little bit hard because some of the people in the area who who had businesses I understand some of the frustration about having yelling psychotic people at their front door every day but some of the interactions were very negative.

[00:04:07]Eventually we had to pursue an AOT order for him.

[00:04:12]And then after we were able to get him on long long acting injectable medications then then things really improved.

[00:04:19]So the challenges are some of these folks are so ill and require so much engagement and it's very labor intensive. We love to do it but it's it's time consuming and um sometimes months or sometimes years before some of these folks actually engage fully.

[00:04:35]Um and so um a lot of the amazing workers who work in this field are kind of underpaid and there's lack of resources in this kind of work and so the challenges are one the severity of mental illness and the and the difficulty with engaging some of these folks. Two some of the public perception about homelessness and I understand people nowadays are getting quite frustrated with seeing so many homeless homeless mentally ill people on the streets but some of the approaches are are a little bit too heavy-handed and needs to need to require more engagement and compassion. Um and then lack of resources and then um uh just kind of changing the public opinion about mental illness and one of the important points is that um this even though some of these folks have been unsheltered and without seemingly having family involved for many years usually when you go back and and get these get to know these people a little bit better and you go back in their history you find out that many of these families have tried for years and years and years to get them help and eventually things just got so bad that the person had to be exited from their housing and became chronically homeless but it's more of the the norm than the exception that people the families did try time time after time year after year to get them help and it just didn't work out.

[00:05:56]>> And hearing you talk about that I can definitely understand. So I spent roughly three years in active addiction and active psychosis. Meanwhile my mom had just been through the mental health system and even though she knew how to navigate it she was also a person living with schizoaffective disorder.

[00:06:12]I kept refusing help and refusing care because I didn't understand that anything was wrong. I actually I thought the opposite. I thought everything was going fine and I was doing really well not recognizing my own episode of psychosis.

[00:06:25]That brings me to the next part which is I mean you know this but a lot of people watching might not. One of the biggest issues is the lack of awareness or anosognosia and that I think leads to a lot of the broader issues we see with schizophrenia. Something I struggled with early on. It's something my mom struggled with. And what I really found fascinating of the documentary is the amount of time you have to take for patients because you understand like they aren't aware. They don't really understand the actions or the things that are going on and it takes a long time it seems like to be able to connect with patients. And I think where where I see that being a benefit is you don't get that time in in the hospital or in the other places where you usually connect with people.

[00:07:13]So can you talk a little bit about kind of that lack of awareness but also like the amount of time that it really takes for someone to be able to be accepting of the idea of taking medication cuz I myself was medication resistant when I started.

[00:07:28]>> Anosognosia is one of the most important issues that we've come to be more educated about in recent years. Looking back on the institutionalization of the mentally ill in the 60s and 70s anosognosia alone explains why that effort fell on its face and and so many people were just left on the streets and were allowed to refuse care when when really they their their brains were wired in a way that they didn't have any ability to understand their impairment.

[00:07:57]And and so fast forward to the current day after seeing so many of these people end up ending up the streets even some programs like act teams may have may may have been a little bit better for helping people but still the the mental health system some of the laws that have a such a high threshold for providing people with assertive or involuntary care which are so enormously high that these folks who are suffering from anosognosia and and maybe weren't assaultive or weren't violent and they weren't suicidal but they just couldn't take care of themselves lying in the streets, not taking care of their wounds and and medical issues.

[00:08:37]Um So in in the approach that we have in like street psychiatry trying to outreach people like Ainoa having anosognosia in the back of your mind always kind of guides the pace of engaging folks and and now more so than before I realized that um trying to engage folks with anosognosia there has to be a point where you determine that like enough is enough and and there's so much neurocognitive damage that happens with untreated psychosis and all these cat scans show brain shrinking cortical matter shrinkage that that you have to really um consider tools like AOT, involuntary hospitalization.

[00:09:24]There's big movement to expand the capacity of state hospitals to take patients because um federal laws for reimbursement for private hospitals typically folks are only going to get hospitalized for like five or seven days and for a person with like 20 years of untreated psychosis to expect them to make enough of a change in in five or seven five or seven days to have any meaningful impact on their trajectory is is really unrealistic. So again this anosognosia is a very severe lack of insight even more so than the lack of insight. It's like it's like a neurological condition that impairs people's ability to make decisions for themselves.

[00:10:03]>> And uh so part of that I I know that you when you do your street psychiatry, a lot of what you talk about is LAI usage.

[00:10:12]And for anyone who's following me that doesn't know, that's a long-acting injection.

[00:10:16]I've talked about my personal use of long-acting injections, but you mentioned specifically for the homelessness population how medication adherence for like oral medication is almost impossible versus LAIs. Can you talk a little bit about, you know, not just the importance of LAIs, but specifically for homeless population or people who can't get in and get medication and get like maybe an easier prescription like like I was able to do early on because that's not always an option for people. Can you talk a little bit about why you're such a vocal advocate for it?

[00:10:55]>> 25 26 years of doing psychiatry and community psychiatry, it's really come to my attention that LAIs have been a huge development in the armamentarium of tools a psychiatrist has for helping people with schizophrenia, especially the ones that are unsheltered. People with schizophrenia, as with other chronic conditions, have less than perfect rate of medication adherence.

[00:11:24]Especially for someone who's unsheltered and who you know, sleeping on the street, constantly afraid of being robbed or victimized, they're not going to want to take any medications that are sedating. They're they're because of the cognitive deficits that often affect people with schizophrenia, they're not going to remember to take a medication twice a day, once a day, even.

[00:11:45]So in my experience the the last 10 15 years especially, the advent of uh monthly antipsychotic medications which last two weeks, one month, two months, three months, six months, game-changer for people with schizophrenia.

[00:12:00]I I really believe that for some of the folks on the streets with with psychosis but and by virtue of them being on the streets for so long, they they probably have they probably represent a very severe segment of the population with schizophrenia that have much more severe symptoms or more severe anosognosia. And so for those folks, I believe the LAIs, long-acting injectable medications, are the only way out of that kind of being stuck in that psychosis and not having the resources or the cognitive abilities or the other supports that someone living in a home or in a with their families would be able to remind them and and it really once I treat a patient and they trust me to give them an injection, then everything is trajectory can totally change and it's it's so gratifying when they someone on the streets trust you enough and they don't trust many people because the way they've been treated by other people, but when they trust you enough to take a shot, it's like so gratifying and it's it's just a it's a the greatest feeling that I have is when when they trust me enough to take the shot and then it's it's very likely that the next shot and the next shot after that they'll be willing to take it again and not not always not always because they have more insight, but it's always based on the relationship with me and the trust they have in me and and and I really appreciate when they have the trust in me to to take medications over and over again. And that actually kind of goes perfectly into the next question I had for you is you spend so much time with these patients and and it seems like you have to put a lot of effort into building that trust. Um I I know how difficult it is as as someone who suffered from a lack of insight to to gain that trust with the patient, be able to have them realize that you have their best interests in mind. I also realized watching the documentary that you put so much patience into these interactions because there are you're going into interactions where people don't really fully understand what's going on. You have to like take a lot of time. It seems like you revisit patients, you're able to build relationships over time and then come back and start, you know, getting trust enough to start medications, stuff like that. Can you talk a little bit about like the level of understanding and patience it takes because this isn't like someone's in your office for an hour at a time. This is you're going back time and time again until you can build that trust. And I think that's what makes what you do super unique and I wish there was doctors like that in every city because I travel all over the country and talk to patients where homelessness in in like LA or Philadelphia, places like that is so prevalent and there isn't someone out there who can, you know, go out into the streets, talk to the patients and build that trust over time. So like how did you get to a point where you could have that level of patience and understanding with patients? That's much of the fun with doing this kind of work.

[00:14:55]The folks who are extremely filthy and hostile and yelling and saying awful things, those are the ones we want the most. Like when we find people like that, we're like overjoyed because those are the ones that really need the most help and those are the ones that me and my team really spend a lot of time trying to get to know. It's important to uh not react too strongly when those folks yell at you.

[00:15:23]You just got to keep coming back. When you say you're going to come back, you got to come back. If you're unreliable, they're not going to trust you. If you can have a you have a just a human to human conversation with them, get to know them, that that really helps a lot. Sometimes you share a meal, break bread with them, that that helps a lot. Long relationships that that progress happens very slowly. Um Sometimes you don't see them for a while. Sometimes, you know, they get locked up, they get arrested by police, sometimes they end up in a state hospital. You don't know where they went. Unfortunately, some of the folks I've been in this field for so long that a lot of the folks disappear from sight and you find out they passed away at a at a way too young age. It's very sad.

[00:16:06]But um and because of the effort I I put into getting to know the person and being invested in them getting better, once a person is starting to get better, maybe getting housed, staying on their shots, psychosis getting better, I don't actually trust anyone else to take over their care. So like usually when I when I when I get to know them from the very beginning when they're on the streets to when they're getting better and getting housed, I I I keep all my patients. I don't trust anybody else to take care of my patients cuz I know that that no one's going to try harder than me to to to keep them stable. And also having the perspective of how difficult it was to get them to the point of recovery is is really helpful and and and with when if if I turn them over to another provider who who didn't see all the stuff that they went through and we went through to get them better and just saw a housed person who was fairly symptom-free, they would be probably inclined to take them off the shot. Or I've seen that so many times where people just fall apart once like I tried to switch them to a different provider. So I just it's just so much emotional and personal investment into helping these people.

[00:17:25]Um I I just love this work. Kind of going off of now, I want to switch over to maybe the difference between Hawaii versus other areas because I've only been here a few days, but culture-wise, everyone's so welcoming and inviting, but when I was watching the documentary An Island of the Mind, right off the bat they threw out some statistics that I was really shocked to hear which was Hawaii was in the top five of homelessness rates and also that roughly 50% of that was estimated to be people with mental illness. So that in itself was shocking to me because in a in a culture where it feels like people are very loving and like very welcoming, I I couldn't believe that that those were the statistics. So do you think that the culture here plays into people either getting access to care or not getting access to care? Do you think there's any difference between what goes on here in Hawaii versus on you know, the continental United States?

[00:18:30]So I think several points here. Uh Hawaii does have a lot of aloha and people generally are nicer I would I I believe and and try hard to be compassionate and help their fellow man.

[00:18:43]Um Other factors that contribute, Hawaii is a Medicaid expansion state. So we do have a lot more access to care for the safety net population of the indigent and homeless. Um We we do have a lot of programs in place to assist people with homelessness and mental illness and we've there's been some recent developments like we uh we built a behavioral health crisis center which is a good entry point for folks who are in crisis.

[00:19:15]Um Uh For the folks who are unsheltered and have serious mental illness, uh by our island geography, we do have the benefit of having people more generally findable than than on the mainland like in in in on the continent.

[00:19:32]Yeah. There's possibility that you might see a patient and they might just wander off to the next town and you you would never see them again.

[00:19:39]Um We do have some folks who come from the mainland who have serious mental illness. I noticed there's overrepresentation of African-Americans in our homeless population with serious mental illness. That's what I've noticed.

[00:19:51]Um Uh uh And but I despite all the the love and aloha and the and the kindness probably getting so big that you see evidence and cracks in in society of people getting frustrated with seeing this homeless problem not get so much better right away. Part of it part of it is shortage of affordable housing which is the case in many jurisdictions.

[00:20:19]And so a lot of people have this perception that the problem is getting worse or not getting better. Some of the folks that are easier to house are getting housed. Some of the patients who have more serious needs like some of the people we're talking about tend to be left behind and after a while more of more and more of those kind of people get left behind giving the appearance that the problem is getting much worse but just that the more challenging patients complex patients are are left behind.

[00:20:48]And so Going back to the original question.

[00:20:54]We do have lots of assets that that help people get the help that they need but there's lots of room for improvement.

[00:21:02]There's also our our methamphetamine epidemic which is really affecting some of our mentally ill people and having schizophrenia plus a severe methamphetamine addiction on top of that makes it very hard to treat people sometimes we can have put them on long acting injectable medications they get somewhat better but without the abstinence or the reduction of methamphetamine they're they're very difficult to house and frequently get into legal trouble with law enforcement and so we have all these issues with drugs access issues some of the rural communities have shortages of providers.

[00:21:44]I think all of that is super relevant. I I grew up in really small rural community in Wisconsin and one of the last questions I had for you was how do you think stigma looks here versus elsewhere cuz I where I grew up mental illness and mental health in general was very stigmatized in which people didn't talk about it and when they did it was in a very negative way like it was the fault of the person who was struggling.

[00:22:10]Given like the culture differences do you think there's more or less stigma here on the islands? So I think overall there's probably less stigma amongst the folks. I think people being part of such a multi-cultural society try to be quite understanding and forgiving. On the on the other hand some of the individual features of different cultures some of the Asian cultures stigma is very high within their communities and so like say Japanese Americans or or like Filipino immigrants come across a lot of folks who say have a young adult son who's starting to have symptoms they don't know how to get help and some of these families like put put their these young adults leave them in the home can't get help and and 20 years later they're still in the home still suffering from psychosis never got the help the family feel ashamed to bring them out for help or bring them into the community. It's really sad to see some of these like middle aged people who are in their houses and untreated with psychosis for decades.

[00:23:22]Uh stigma is coming more apparent with again with the homeless problems and and seeing the seeing the people who get frustrated and don't maybe don't understand as much as other folks about why mental illness happens.

[00:23:41]You see people things on like social media posts or like posts to articles about mental health laws being changed you just see some horrible comments ignorant and hateful comments about mentally ill people.

[00:23:57]>> [clears throat] >> So that's one of the things that's so hard about this job and and kind of being positive all the time it it wears you down to hear people say such hateful things to about mentally ill people homeless people too. And unfortunately if you want to see an example of some of those comments be sure to check my comment section because they're also there.

[00:24:19]>> [laughter] >> A lot of what I've noticed in my journey as an advocate is I talk a lot to patients but also I think the most the most of my audience is caregivers. A lot of people who follow me are either people in recovery of early psychosis or people who have loved ones and they're they're unable to get them help they're unable to get them treatment. Do you have any like words of hope cuz I feel like as people with schizophrenia and people that have loved ones with mental illness we are in such a a pool of hopelessness. That's how I felt very much early on in my diagnosis and I recognized peer support was a huge thing for me where it gave me hope cuz for the first time I saw people living and thriving with mental illness. Do you have any words of hope for people or their families that that you can give?

[00:25:10]>> So such an interesting topic. So even though I I mostly spend time with homelessness I I do work with a lot of family some of them are quite wealthy families who have a son who's in their 20s or 30s who has schizophrenia. Even those families with all the material wealth that they have often have times finding access to care overcoming that stigma of of being willing to talk about their loved one.

[00:25:37]Even those people have have difficulties finding help for someone who doesn't want to leave the house and get help who has anosognosia.

[00:25:46]So what one of the things that I also do one of the one of the needs that I really noticed in the community probably in Hawaii there's probably hundreds of families who have a loved one who's starting to have first episode psychosis but family knows nothing about it wondering what's going on they don't know where to turn for help call the police police comes the person says I'm fine officer you can go away I don't I don't want to talk to you that goes on for months years the behavior gets worse. So one of the things that really compels me is probably because some of the other documentaries that have been made about my work people will randomly call me like once a month or couple of calls a month and they'll say Dr. Chad you helped my my cousin's kid who had schizophrenia my my my kid has the same kind of symptoms we tried to get him him to the hospital they didn't admit him the police wouldn't help he's we're trying to get afraid of him he's very paranoid and so how do you how do you not offer to help someone like that when when I have the tools and the desire to to and and not if if I I wouldn't be able to sleep at night if I if I refuse refuse to help them and so a few times a year I I I meet with these families I go go to their house try to meet with the loved one who's suffering and then we come up with a plan and that was one of the compelling stories that came out during the NAMI meeting is one of the one of the ladies who was living in rural Big Island her family reached out to me for help and so we had to I had to go out there and try to help her and it involved like engagement taking out my outreach workers trying to build trust and when we were able to get her on a long acting injectable then everything kind of fell in place and she got so much better and now the son can go to college and the family can relax and she's went on a trip with her son to the Orient and some amazing stuff. Yeah I was I was really grateful that was Kai right? Yeah so I got to hear Kai's story and reaffirmed everything I've heard about you and your work and I want to thank you for taking this time to to do this interview and tell people a little bit about your story and your journey. So before we end the interview do you have any resources or anything you want to recommend for anyone watching or any organizations that you want to shout out? So I'm on the executive committee of the Schizophrenia and Psychosis Action Alliance amazing international advocacy organization which does research does support groups all sorts of other initiatives with they published cost of schizophrenia study a few months ago which which revealed that in 2020 the cost to families and the society and the system was like 280 billion dollars.

[00:28:49]So I want to shout out to both that organization which I'm super proud to be a part of and also Street Medicine Institute which I'm also a part of and another amazing organization of people who are very well intentioned and very passionate about taking care of un-sheltered people with mental illness.

[00:29:04]Thank you again for agreeing to do this.

[00:29:06]It was a very impromptu meet up we had kind of make this work cuz you're going to another island tomorrow to work with patients and I am leaving Hawaii unfortunately to go back to the cold Wisconsin area.

[00:29:18]>> [laughter] >> And so I I do want to shout out one more time an Island of the Mind is documentary be sure to check that out and thank you again for for joining me and if anyone has any questions leave them down in the comments. As always remember my name's Cody don't worry I'm real.