Mentally ill Homeless essay
Homelessness and all the incoming problems have become more visible in the big cities across the globe. Homelessness is often associated with mental disorders. It is mostly connected with the situation in the UK where a policy of global closure of psychiatric institutions led to a huge number of mentally ill people living in the streets. The UK and the USA provide a large number of literature and studies of the issue while European countries pay less attention to this problem. However, the problem has gained international character and has the same nature and background all over the world. Bhugra (2007) mentions rapid industrialization, population increase, land and cheap housing reduced availability, migration, unemployment, closure of institutions proving casual accommodation for people, as the main problems resulting in global homelessness. Charity seems not to be able to solve the problem.
The background and studies of the issue
The universal definition of homelessness is based on home/roof/shelter while it does not mention other aspects of people’s social living like job, social assistance etc.
Wright as cited in Bhugra (2007, p. 5) gives a definition to homelessness as “a lack of customary regular access to a conventional dwelling unit”. The differentiation is made between those people who have no access to any kind of housing and those who live in a temporary accommodation or ‘marginal housing’.
Bhugra (2007) emphasizes that the level of psychiatric disorders among the homeless people may vary “according to diagnosis, method of diagnosis and methods and sources of collection of samples” (p.5). Functional psychoses among those who use night shelters prevails (Bhugra, 2007). Another diagnosis which turns to be rather wide-spread among those who stay in hostels is schizophrenia. Thus, controlling the level of mental morbidity among homeless population has become a serious problem.
Recent studies on mentally ill homeless have been cross-sectional and experienced a lack of methodological background. It is necessary to assess the extent to which homeless people are able to move in and out of their homeless position and to investigate the level of mental health contribution to the issue.
Various sources state the problem of different types of mental and psychological disorders among homeless populations. Further investigation of the problem reveals that homeless people do not have opportunity to receive proper help from some service agencies and they do not have trust in various statutory health services. The problem of inflexibility of such institutions worsens the situation.
The number of homeless people with untreated psychiatric illnesses is “one-third, or between 150,000 and 200,000 people, of the estimated 744,000 homeless population” (Treatment Advocacy Center, 2011).
The most recent research of the problem reveals that mental disorders cases varies from 80-90% in USA, Australia, Canada, Germany and Norway to 25-33% in Spain and Ireland, while French researchers reveal 44 % of schizophrenia cases and 31% cases of substance use disorders (Gadit, 2011, p.299-300). The prevalence of mental disorders varies from 80-95% in USA, Canada, Australia, Norway and Germany to 25-33% in Ireland and Spain. The most common mental disorders involve affective disorders, drug abuse, personality disorders, schizophrenia, depression and various psychotic disorders (p. 300). Barry and Farmer (2001) supplement the list with post-traumatic stress disorders, mood disorders, organic brain syndrome, developmental delay, anxiety disorders and disabilities.
The problem of homelessness and its relation to mental disorders is rather complex. Mental illnesses are often seen as global factors leading to and perpetuating homelessness. Bhugra (2007) mentions other minor factors like low cost housing not being available, unemployment increase and in addition, loss of manufacturing base is observed and global closure of hostels which used to be of direct access for homeless people. The last ones used to provide constant service for mentally ill homeless individuals.
The distinction between ‘the homeless mentally ill’ and ‘the mentally ill homeless’ has been argues (Bhugra, 2007, p. 99). However, one of the major problems of homeless mentally ill is their health issues and it is emphasized that there is not big difference between those homeless people who suffer mental disorders and those who do not. “Not mentally ill’ homeless people are likely to have many mental health problems and the ‘mentally ill’ homeless may have non-psychiatric problems that arise from the socio-political elements affecting all homeless people” (Bhugra, 2007, p. 100). The problem of homelessness is often examined in the broad socio-political and socio-economic context, while personal biography and health problems are seen as complementing factors.
German psychiatrist who first addressed the problem of mentally ill directly was German psychiatrist K. Wilmanns (Fisher & Collins, 2002). He noticed that a large number of homeless people who were transferred to his hospital had diagnosis of schizophrenia. Bhugra (2007) provides the data that have been collected in 1960s – 1970s. Homeless people with the diagnoses of alcoholism, schizophrenia, affective disorder and personality disorder were commonly found in hostels and hospitals.
More recent research revealed that such symptoms as thought disorder, delusions and hallucinations followed schizophrenia by popularity. Alcoholism was minor problem. The issue of high prevalence of psychiatric disorders among homeless people provoked a discussion, whether mental illness may be considered as a significant factor for becoming homeless or whether constant stress of being homeless causes psychiatric disorders.
Origins of the problem of mentally ill homeless people
Fisher and Collins (2002) provide a detailed overview of the factors specific for the mentally ill that cause homelessness. The authors divide all the factors into several groups. They mention hospital issues, hostel issues, schizophrenia issues and access to housing among the groups of factors. Hospital issues unite several factors. Hospital closures are suggested as one of the main factors that led to the increase of mentally ill homeless people. This process was defined as psychiatric deinstitutionalization which has been going for about thirty years. Psychiatric beds reduction was initiated in 1954 and the number of beds has been cut in half. Hostels have not improved the situation. Another problem that relates to hospital issues is inadequate acute beds. Global closures of hospitals and beds reduction have resulted in poor situation with health care provision for homeless people. They do not stay enough time in hospitals and experience the lack of treatment. Homeless individuals are often discharged as soon as possible. Thus, discharge policy is stated as one more factor that contributes into mentally ill homelessness. Medical practice shows that some patients are often discharged without proper treatment and even treatment plan. Mental Heath Act, 1983 requires a multidisciplinary council of hospital staff, social workers and patient family to be held before discharging the patient (Fisher & Collins, 2002). Proper treatment and support plan should be guaranteed to the patient after discharge. However, it hardly sounds realistic in the situation when there are no enough beds for patients and psychiatric wards being overcrowded with patients waiting for a bed to be freed.
Hostel issues include nature of direct access hostels. Most direct access hostels have inherited most characteristics of old psychiatric hospitals. The users of the hostels are offered total care of low standard and no individualized approach is presupposed. They offer Food, shelter, clothing, assistance with benefits and re-housing. But the organization of the service is rather primitive and the system of medical examination is rather informal as well. Thus, hostel system does not provide any global solution of the problem. The problem of regular hostel closures cannot but worsen the situation. One of the major reasons for closing was accommodation problems. The conditions of living were too severe to be offered for homeless people. The lack and control and corruption of hostels staff did not allow relying on the hostels any more. The spread of diseases and poor conditions became the reasons for closing a large number of such institutions. The nature of replacement schemes contributed into mentally ill homelessness as well. The replacement schemes were often arranged as secondary or tertiary referral institutions. The procedure of access to such hotels became rather complicated. People with long-term mental disorders were often ignored. The problem was generated due to direct access accommodation disappearance.
Schizophrenia issues are connected with the fact that most hostels were arranged as the housing for travelling people and required a number of procedures to get passed trough before entering an institution. As many people with current mental illnesses were ex-patients of psychiatric hospitals and suffered schizophrenia, it was very hard for them to carry on the negotiations before using the hostel service. The atmosphere of the hostels may be characterized by the wide range of various odd behaviors and the policy of ignoring from the side of other residents and staff. The emotional climate of the institutions was rather favorable for gaining various kinds of mental disorders.
The last group of factors is mentioned as access to housing. Alinsky and Iczkowski as cited in Fisher & Collins (2002) emphasized that people with mental health problems continue being discriminated in the housing market. The lack of money makes it impossible for them to solve their accommodation problem.
Barriers to service provision
The problem of poor services for mentally ill homeless people may is based on the barriers that prevent service provision. Fisher & Collins (2002) give a systemized classification of these barriers. The first group is stated as institutional barriers. This group includes the problem of appointment systems which mean that homeless people have to control their time as opening hours of medical institutions or hostels are limited for them. The system of catchment areas worsen the situation as psychiatric services are organized by territories meaning that every psychiatric team is responsible for proving service on a particular area. Their service is only available to people who live within this area. Thus, people who do not have an address have no access to the service. Rigit working practices are also stated as a barrier for service provision as in spite of the well-known fact that metal disorders can be best treated at home, psychiatric services remain accessible only in medical institutions. The next barrier within this group is stated as follow-up arrangements. A huge number of mentally ill homeless people are out of psychiatric contact because they often fail to come and receive medical care in time. Thus, they become lost for permanent medical examination and treatment. The problem of community care remains an open question as these functions have not been seriously taken by any community representatives. Inter-agency co-operation is mentioned as one of the barriers as well. Institutions that provide any kind of assistance for mentally ill people do not have a system of effective cooperation. The problem of communication between the agencies which help homeless population with mental disorders remains unsolved. It makes the whole system of assistance to this group of population function on a low level.
Another group of barriers is professional attitudes. This group comprises such factors as stereotyping which means that psychiatric staff perceives homeless people as unreliable and low sort of people. The problem of multiple needs have roots in the fact that the discussed group of patients requires a wider range of services while the system of assistance remains mono-disciplinary. Clinicians experience difficulty in providing such patients with adequate help. One more factor is constituted as the lack of ‘substrate for health’ (Fisher & Collins, 2002, p.107). It means that homeless people are often placed in such social and economical conditions that initially influence their health. Thus, providing only medical help may be useless. Myth of mobility has become one more serious barrier, as it is often believed that homeless people tend to change their location very often. Thus, there is not need to be involved. However, this group of population rather tends to keep a certain territory on regular basis.
The last group of lifestyle barriers involves the issue of psychiatric treatment which often occupies the last place in mentally ill homeless person’s list of needs, as priorities are give to shelter, food and clothes. Poor access to psychiatric services is stated as one more barrier comprising this group. Homeless people do not have their regular GP and psychiatric service tend to have rather casual character. The problem of mobility also causes problems with regular and adequate treatment as in many countries homeless people who insignificantly change their location go into the responsibility of another psychiatric team and previous treatment strategy can not be taken into consideration. And the last barrier is mentioned as distrust in officials. Homeless people tend to be suspicious when they meet any representative of state power and state institutions. They remain the most legally unprotected group of population and may be arrested, penalized or just do not meet the requirements of the institutions which should provide them with some kind of service or assistance.
Conclusions and Suggestions
The problem of mentally ill homeless people remains one of the hot-button issues in many countries of the world. UK, USA, Canada and Australia have made rather significant efforts to solve the problem, while European experience is not at the same level.
Fisher & Collins (2002) suggest three models of effective health care provision. One of them is ‘separate services’ model which presupposes that all kinds of services for homeless people should be separated from those for other groups of population. They should have staff and specialist who will provide service especially for them and exclude the situation of being ignored. This system may work well and contribute in the problem solving. Another model is stated as ‘special schemes that assess and intercede’. This model presupposes homeless people informing about their rights and encouraging protecting them while medical institutions should be encouraged to provide adequate service for this group of people. These schemes should provide advocacy and support for al kinds of services for homeless people.
And the last model is ‘fully integrated services’. The system mostly concerns not homeless people but people who work in the system of services for homeless population. They should be properly arranged and controlled providing integrated services.
One of the methods of coping with the problem of mentally ill homeless people may be ‘psychiatric emergency services’ (Gillig & McQuistion, 2006, p.83). These services must be utilized by people with mental disorders. They must be provided timely and on regular and individual basis. Another important point of this strategy is building relationship with people having mental disorders. Cooperation is the best way to overcome the problem. This method may become a good alternative of hospitals and jails.
In spite of numerous discussions and publications on the issue of mentally ill homeless people, no universal solution had been suggested. Coping with the problem requires detailed study of the problem background and peculiarities characterizing the situation in certain country. Social, economic and political sides of the problem should be carefully considered. A number of pilot projects have been already initiated to solve the problem in various states. However, corrections should be regularly made and they should be improved for further implementation.
