Plight of those with ‘dual diagnosis’ most evident in the homeless

On a late evening in April 2017, I sat in an emergency accommodation hostel, a place where there are no facilities for you to stay during the day and so you are put out on to the streets every morning.

But I didn’t know that yet.

In fact, I didn’t know much at all about how the system worked.

There were three of us packed into a corner in a stuffy room – a staff member, somewhere in her early 40s, with brown hair and glasses; a dark-haired girl with kind-looking eyes in her early 30s; and myself, 31.

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The staff member introduced herself. Denise ran through house rules – no drinking or drugs (there were needle bins everywhere, so I guessed, correctly, these rules were routinely ignored). We had to keep our rooms clean and, finally, pay the rent.

I snapped out of my reverie when she asked me my name. “Chris” I announced cheerfully, extending my hand. “No, your full name.” She started running through the questions on a form. My answers were fairly straightforward, until it came to “any relevant illnesses?”

I hesitated. Disclosing mental illness had gotten me in trouble before in work, but then I had just been through a long few weeks of mental strain, so I thought it was better to come clean. “Schizoaffective,” I replied.

It turned out the girl beside me, Milly, was an Irish citizen with a childhood spent on the run from war. She and her family had gotten safe passage (before the days of direct provision) and eventually wound up in Ireland in a citizenship integration programme, where she had completed her education.

And now, we had wound up here – the first night in a homeless hostel for both of us. I didn’t know what to expect.

Homeless hostels

One of the things that shocked me most in the homeless hostels I stayed in over the coming months concerned “dual diagnosis”. It can be defined as an illness which a person experiences when they have both an addiction problem and a mental health issue.

I have had had my own run-ins with drinking to excess, particularly during my college days. In later years I attended day hospitals, psychiatrists, clinics, psychologists, therapy and harm-reduction sessions with psych nurses. I put a lot of work in.

I say this only because it has resulted in so much time waiting in psych clinics, attending day hospitals and being behind doors of locked wards. I have become quite familiar with the often contextually understandable yet bizarre behavioural patterns of people in deep psychological distress.

The tell-tale signs of unmanageable anxiety and hopelessness within the hostel – as well as more profoundly affecting schizoid and personality disorders – coupled with rampant drug abuse, brought me to the conclusion that nowhere was the plight of dual diagnosis more evident than in the homeless populations.

According to Dr Fiona O'Reilly, manager of Safety Net Primary Care – a charity that provides healthcare to society's most marginalised – those with dual diagnosis "are excluded from a large section of the services for people with mental health issues, in psychiatry, because of the addiction. Then you'll be excluded from the places that treat addiction because of the mental health issues. So it's catch-22.

“There have been positive moves in recent years to get people to talk about mental health, but in Ireland there is colossal stigma around mental health and an equal stigma around addiction. People are criminalised rather than cared for. One of the doctors that works with us recently looked over her own records and found more than 80 per cent of the patients she’d seen with mental health problems also had an addiction.”

Care strategy

Mental health teams, who do not deal with active drug or alcohol users, prevent homeless dual diagnosis patients from gaining access to the help they need.

Donal Ryan, a psychotherapist based in the mid-west, has tried to implement a care strategy specifically for dual diagnosis called No Wrong Door. According to the strategy document, "we propose to develop a fully integrated and recovery-focused community service for adults with [dual diagnosis] in the mid-west. It is envisaged that such a service could serve as a bridge between primary and secondary care, work under a shared-care model and help improve access to and engagement in treatment as well as outcomes for people with [dual diagnosis]."

The document also points out that medical care for those with dual diagnosis is poorly lacking, especially considering there has been a trend of increasing in specialisation in the medical sphere. This specialisation model is counterproductive in treating dual diagnosis, as the document states explicitly that integrated care teams are needed which span across disciplinary fields.

Lack of privacy also has an incredibly detrimental impact on mental stability

Although the No Wrong Door document was discussed at an Oireachtas hearing and received a positive reception, it has effectively been ignored ever since.

There are further complications with homeless mental health teams who refuse to treat homeless individuals presenting with anxiety, depression, or PTSD. The bottom line, apparently, is that GPs can deal with these illnesses. Yet these are the most common mental health disorders brought on by living in chaotic environments.

I have seen it time and time again in the homeless hostels. People experience high anxiety because of the disorder and unpredictability of day-to-day life – such as not knowing which room you are going to be sleeping in.

Lack of privacy also has an incredibly detrimental impact on mental stability. People are made desperate in such conditions, and desperate people often self-medicate in the absence of hope, which homelessness breeds.

To take the edge off, many resort to smoking cannabis. The same applies to PTSD. Waking nightmares, night terrors and insomnia, as well as depression, can lead people to drink in an attempt at blotting out the trauma of psychological problems.

Trauma

Homelessness can also breed dual diagnosis since homelessness itself is a trauma and the aftermath leads people to do things they normally would not resort to if they were living in stable environments.

Dr Austin O’Carroll, who runs a GP service for the homeless on Mountjoy Street, Dublin 1, says that with anxiety and depression “the symptoms present because people are anxious about being homeless. They don’t want to be homeless. There are some people who have stable accommodation and they’re also anxious about losing their homes. Probably the things that caused them to be homeless gave them anxiety before it came to that.”

Dr O’Carroll is also vocal about homeless patients presenting with depression. “It tends to be very severe,” he says. “You can get people presenting with low mood, but much more often you tend to get people at the very bottom. They will have had suicidal thoughts, suicidal feelings.”

“At the age of about 16 I began to feel ‘different’ to others,” says Sarah, now in her late 30s. “I developed anorexia, depression, anxiety and agrophobia. I remember telling my mother that I wanted to die.

“I fell into the trap of addiction when I took my first drink in my 20s. It calmed my anxiety and tormented head, and helped me to stay in one piece. Basically, I was seeking escapism from the nightmares, intrusive thoughts and suicidal feelings. My drinking became heavier over the years and my tolerance increased so I needed more. Looking back now, I can see the progression of my disease.”

In 2017, after several attempts at rehab, Sarah found herself homeless and was admitted to a psychiatric ward following an overdose. Having adjusted Sarah’s prescription, the ward then transferred her to a rehab centre, where she did not get an easy time on account of her dual diagnosis.

Medication

“While I was in treatment the counsellors were very anti-medication and practically everybody was on some form of medication. A huge percentage of those seeking treatment also suffered with bi-polar, depression, and various personality disorders and so on.

“Their take on medication was that it was unnecessary and that there was nothing wrong with me other than addiction. I was told by them that I wasn’t suffering from depression. They told me that as long as I continued taking antidepressants I was still in active addiction. This really upset me, so I eventually attended my GP and explained my situation. He wasn’t at all happy to reduce any of my medications.”

According to Dr O’Carroll, “what happens is that with traditional [non-addition] psychiatrists, a patient will generally be treated by the Access Forum – the psychiatric services specifically for the homeless populations. If there are drugs involved they would tend not to treat. They would say, ‘that’s not for us that’s for addiction psychiatry’.”

Jackie would trade her prescription medicine – heavily sedating mood stabilisers and antipsychotics – for crack

The problem with addiction psychiatry is that you have to be attending a clinic for methadone, where there are psychiatrists in place. Addiction psychiatrists used to visit in satellite clinics, but at the moment in Dublin you only have Trinity Court.

However the treatment plans lack aftercare or interdisciplinary care. Patients experiencing dual diagnosis need continued aftercare to fully recover from the abjection and pain that drives addictive behaviour, as well as the mental health issue(s), which can take years to find a medical and therapeutic balance with.

This leaves the homeless population at even more of a loss. Detoxing from a drug is one thing, but being homeless and returning to a chaotic environment where you are constantly surrounded by drugs can only compound the problem.

Drug users

“Being homeless and having dual diagnosis, the thing you need the most is a home,” says Dr O’Carroll. “So it has to be a total system response. I think the reason there isn’t any service for dual diagnosis is that the most stigmatised communities in our society are drug users, and with drug users there’s a real ethos that they’re to blame for their condition. It’s a double whammy, because the single biggest association with drug addiction is poverty.

“Poverty comes from the fact that we live in a system where there is huge divide between the wealthy and the poor. So we create positions where there is poverty, which causes drug addiction, and we say, ‘in fact, you’re to blame for your drug addiction, so there’s no sympathy for you’.

“When a person dies on the street there’s huge public sympathy if they are homeless. If it was a drug addict who died there’s a lack of sympathy and you don’t see that story in the papers.”

In the emergency hostel I saw people with dual diagnosis every day. BPD, bipolar, schizoid and psychotic tendencies – with a large number of those affected also deep in the throes of addiction.

I recall Jackie with great sadness. She was young, feisty, bossy and had serious alterations in her mood. She was a heavy drug user, and would seem to change her personified identity almost daily, telling stories from her childhood. Stories that made me disassociate with horror – as if they were funny anecdotes. One such story involved being forced to eat her own vomit as a little girl. It was hearing things like this that made me much more aware of the human side of addiction, which is something very infrequently approached.

Jackie would trade her prescription medicine – heavily sedating mood stabilisers and antipsychotics – for crack from one of the dealers that lived in the hostel.

To quote from (addiction expert) Gabor Maté: “Like patterns in a tapestry, recurring themes emerge in my interviews with addicts: the drug as emotional anaesthetic; as an antidote to a frightful feeling of emptiness; as a tonic against fatigue, alienation and a sense of personal inadequacy; as stress reliever and social lubricant.”

Life-changing anxiety

Drug addiction, however, is just one side of the story. When people are experiencing catastrophic mental health issues as well, it complicates everything and makes recovery extraordinarily difficult. It also results in largely inaccessible services.

Take Cyril. A young man in his early 30s, he is currently experiencing homelessness, and suffers from profound life-changing anxiety. Since becoming homeless, he has become a far more active drinker than before. “Alcohol was always a social thing for me,” he says. “But very recently my drinking has escalated through the roof. It just happened, and I never thought that that would happen.”

It is worth noting that Cyril had enrolled on a CBT (cognitive behavioural therapy) course, which he found beneficial, but was thrown out after he relapsed.

As Ryan points out, people who experience dual diagnosis have very complex needs because it is so all-pervasive in that it is operates in two major arenas of healthcare. It is not that the doctors or nurses or psychologists aren’t trying to do their best – the infrastructure simply isn’t there for dual diagnosis.

Ryan says dual diagnosis is “the norm, rather than the exception” in his cases, and this is with housed communities. Think of the gap between the homeless – living in traumatic and survival mode – and the services they so desperately need in the face of such a large scale epidemic.

Chris O’Donnell is a musician and journalist with an interest in social issues. She is also an intersex advocate, and is returning to university in September