An estimated 40 per cent of the Republic's 5,000 homeless are mentally ill, writes Kathryn Homquist. Experts are divided on why they have fallen through the cracks of the social services system. Are they on the streets due to the closure of psychiatric hospitals, or is it a 'lifestyle choice'?
Do some mentally ill people want to be homeless? Noreen Byrne, communications director of the Northern Area Health Board of the Eastern Regional Health Authority thinks so. "Some people drift and drop in and out of services. It's a lifestyle choice," she asserts.
The same point of view is taken by Martin Rogan, director of mental health and addiction services in the South Western Area Health Board of the Eastern Regional Health Authority. The SWAHB is currently developing services for homeless mentally ill people on the south side of Dublin.
For some mentally ill people homelessness is an "alternative lifestyle", Rogan believes. "We get lambasted for not helping the mentally ill, and then we find out that this is where they are at in their lives. It's a question of civil liberties. We can't lock people up. If you are using drugs or alcohol and unco-operative, you are out in the cold."
A vicious cycle of living on the streets, in prisons and in hostels has become a way of life for many severely mentally ill people. Jack Buckley, director of nursing at St Brendan's Hospital in Dublin, says: "There's no doubt about it. There are a significant number who choose to be homeless. Regardless of what service is provided, they won't use it. Only when a person commits a crime can you enforce compulsory admission."
The idea that homelessness is a lifestyle choice angers two consultant psychiatrists in the frontline, Patricia Casey and Kevin Malone of Dublin's Mater Hospital.
"I don't believe it. I think it's a cop-out, a rationalisation for the indifference and inertia," says Casey. "I don't know anyone who wants to sleep in a sleeping-bag on the street. Everyone wants a roof over their head and wants to know where their next meal is coming from and wants to be valued and cared for by other human beings."
Malone, who is shortly to take up the chair of psychiatry at St Vincent's Hospital, Mount Merrion, Dublin, says: "The idea that there are people who are beyond hope - I think it's awful. It's not even in line with international mental health practices. Ireland is 15 years behind. The underbelly is not pretty and the lip service that is paid to 'helping' these people would make you sick."
Casey gives two examples of cases she has come across:
A 22-year-old woman, well-educated but a wanderer and a drifter, is sleeping rough by the canal in Dublin. She's in an odd state, obviously in distress. A concerned passer-by stops and speaks with her. The girl is homeless, hungry, distraught. The passer-by brings her home, gives her a meal and a bed for the night. The girl seems grateful, but during the night she tries to kill herself. Her host discovers her within seconds of losing her life.
The girl is brought to the casualty department of the Mater Hospital. The psychiatrist cannot find a bed for the girl. No one will take her. She has a southside city address, so on the north side there's no hostel place, no outreach programme, no safety net. Somehow, the hospital manages.
Another case: a man in his 20s is suicidal. He too is found by the canal. He has nowhere to sleep, no money, no food. He has left an abusive family situation. There is no "home". He too is brought into the Mater Hospital casualty unit. The homeless services don't have a place for him because, officially, the man is not homeless. To be defined as "homeless", you must have been registered as living in a hostel for the previous three months. But the health board can't place him in a hostel if he is not defined as homeless. It seems to be Catch 22.
Mary Higgins, of the Homeless Agency, points out that some homeless mentally ill people exhibit such "challenging" behaviour that no hostel wants them . . . so they haven't a chance of being officially defined as homeless.
Every week, the Mater Hospital psychiatrists see three or four such desperate situations. "It's crazy - ludicrous that you have to be in a hostel for three months before being considered homeless," says Casey. "Junior doctors spend many hours in the middle of the night fighting over available beds and trying to get hostel places."
Malone describes the Mater as "like Heathrow", as psychiatrists juggle beds and people in crisis. People with mental health problems get a minimum of care - 12 days in hospital for a public patient, compared with six months for a patient with private health insurance. The Mater has only 10 acute beds for mentally ill people, and an additional five general hospital beds. Seven out of 10 beds are occupied by mentally-ill asylum-seekers.
Fifteen beds in total. Consider that the Mater's catchment area of 25,000-30,000 people in north inner-city Dublin has the greatest concentration of homeless mentally ill people in the Republic. Of the 5,000 homeless in the State, about 40 per cent - 2,000 people - are mentally ill. Eighty per cent have at some point consulted a doctor about the symptoms of mental distress.
THE Homeless Agency's Mary Higgins sees the organisation of mental health services into catchment areas as being a major part of the problem. Homeless people drift and may be picked up on the street in a catchment area different from the one they were getting help in. There is "huge confusion" when people fall through the cracks in this way.
"Embryonic" is how Casey describes services for homeless people with mental illness. The Eastern Regional Health Authority may have great plans and a model pilot programme for 150 men (no women) at Usher's Island, but psychiatrists such as Casey are not seeing any benefits in the frontline.
The crisis of severely mentally ill people living on the streets is traced back by some to the closure of psychiatric hospital beds in the 1980s, reducing the number available from 20,000 beds to the current 2,000. For Higgins, the origins of the problem are obvious: psychiatric beds closed while insufficient investment was being made in community support.
Martin Rogan, director for mental health and addiction services in the South Western Area Health Board of the Eastern Regional Health Authority, takes a different view. He points out that, in the past, there were people in psychiatric hospitals who should not have been there - being a single parent or gay was enough to have you committed. He says that everyone who left hospital was given appropriate accommodation in the community.
That's not the way Mater consultant psychiatrist Kevin Malone sees it: "Current services are only scratching the surface; there's almost nothing. To solve the problem, you are talking about investment of time and money, and that's not going to happen."
Psychiatrists are supposed to treat mental illness, but Malone says that for homeless people with mental illness, a stable place to live is the treatment. Throughout the Eastern region, there are 27 beds specifically for people with mental illness, but this isn't enough. Currently, Malone is trying to find hostel places for 15 homeless people with mental illness - he always has about 15 people on his books with nowhere to go. He says what is needed is an organised system of mental health hostels where people have a place to sleep, food to eat, the social supports and the medical expertise they require.
It's not enough just to give people psychiatric drugs - and drugs aren't always appropriate, he adds.
Jack Buckley works with about 40 men daily in a programme for homeless, mentally ill men at Usher's Island. Men only are included in this successful programme and they must be in a hostel for three months, and thus defined as "homeless", before they are eligible. Is Buckley happy with that?
"My own definition of homelessness would be somebody who is sleeping in the Phoenix Park or in a doorway. If you have a roof over your head for three months, you're not homeless," he says.
So are the "homeless" with severe mental health problems really being helped? Buckley is concerned at the growing number of homeless young women with mental health problems. They are a vulnerable group, many of whom turn to prostitution in their attempts to survive. "You see 17 and 18-year-olds on the streets accompanied by men twice their age," Buckley observes. "To be homeless is bad enough, but to be homeless and mentally ill is a double-whammy," he says.
On the other hand, many people with mental health and addiction problems are "non-compliant" and may be incapable of accepting help when it is given.
Malone points out that many homeless people with severe mental illness have enough difficulty getting out of bed in the morning, let alone getting to an appointment at a particular time in a particular health centre. In US and Canadian cities, such as Chicago and Toronto, services are brought to the person in need, rather than the other way round.
Martin Rogan agrees that some people need services to be brought to them, but adds that this is costly and staff-intensive. It costs much more to bring services to the streets than to bring people off the streets and into the services. Nevertheless, a dedicated team is being set up in his area to reach out to people with mental illness living on the streets.
Rogan is also enthusiastic about peer advocacy, in which people who have experienced mental illness listen to people experiencing difficulties and help the services decide what they need. The first group of advocates has just been trained, and a second group is in the process of being trained.
Rogan introduces me to John, a man who has had mental health problems and was once homeless. Rogan believes that John will prove his point - that some homeless mentally ill people are immune to help until they're ready to accept it.
John, a diagnosed schizophrenic, was rescued from the streets, as a teenager, by a couple who brought him home and convinced him to return to his family. Twenty years later, he is off medication and has his own business and a family.
"Some people are on the streets because they cannot bear to be contained in four walls; four walls is a prison," John says. "Some people need the freedom of the streets and won't ask for help until they are ready."
Maybe so. But put yourself in that situation. If you are not "ready" to ask for help, perhaps it is because the type of help being offered isn't what you need.
