A GROWING PROBLEM
Many patients who are afflicted with acute mental health problems are being discharged from hospitals without a home to go to. They find themselves out of orbit in a sort of “No-Man's Land” without continued care or follow-up addresses.
"I think Scotland needs more psychiatrists, psychiatric nurses and psychologists. We need more hospital beds too and more community psychiatric nurses. There is a lot of talk these days about 'mental illness' but it is very hard to educate people about schizophrenia,” stated a 47-year-old woman from Scotland-- who was diagnosed with schizophrenia in 1997. Mary Hamilton {not her real name} feels deeply concerned and anxious about how so many people still can't acknowledge the depth and complexity of this condition and the all-too-often absence of available medical treatment for those with mental health problems.
Despite a massive publicity campaign to make the public more aware of this problem via articles, posters and post office stamped letters which I receive, many patients find themselves being discharged from hospitals and prisons onto the streets with nowhere to go. Indeed, without any family, friends or caregivers to fall back on they can end up aimlessly roaming the streets. Their distinct presence at railway stations and on the streets has become so frequent that it is now seen as a normal part of the landscape. You have the 'normalization' of discharged patients walking around the streets without receiving or taking any medication.
It is fair to say that most people don't know how to interact or communicate with patients never mind understand them. People are often confused by the condition. Even worse, a local doctor might simply tell a patient who suffers from manic depression "We all suffer from depression" or "Just get some sleep or go to the pub" or even "Wise up and pull yourself together." A more extreme encounter might include driving someone out of a pub for annoying someone wishing to have a quiet drink. The direct impact of such a terrible reaction can spell disaster. Those misunderstood and misjudged people end up on the streets. They represent a significant and striking number of the homeless. It is impossible for anyone who actively works with the homeless to avoid them.
MAKING SENSE OF IT
It is essential to see it is not only the public who often don't understand mental health problems but even specialists who struggle to make sense of things.
Mary Hamilton told me, "I was looking through some old paperwork and found a list of all my various diagnoses over the last 24 years. To begin with I had a 'psychotic episode in 1997, then it became 'schizophrenia', then it became 'schizophrenic disorder', then in 2006 it became 'psychosis in manic depressive disorder, and then it was back to schizophrenic disorder. Next came ‘Bipolar Disorder.’ Recently a doctor said it is 'schizophrenic affective disorder.' Basically, I am on the 'Schizophrenic spectrum'."
It is important to understand schizophrenia is a diagnosis indicating a patient’s loss of contact with reality. Schizophrenia can include a patient losing control of their mind through suffering false hallucinations and delusions which distort his patterns of thought and verbal communication. The frightening thing about this condition is the patients lose control and genuinely believe the voices echoing through their minds. Some patients don't completely recover and can be without regular work for years. They can be stigmatized by not only local people but even members of the family can avoid them. For instance, some relatives of Mary Hamilton suggested to her parents that they should throw her out of their house!
Many of those patients who claim government benefits are frowned upon as 'work shy' or 'free loaders'. Some people actually believe the mentally distressed are sometimes feigning illness to avoid work. However, if anyone understood the immense suffering which those patients undergo they would swiftly abandon such childish and myopic notions. Nobody welcomes such an experience. Nobody deserves such an affliction! The terrible side effects of various more dangerous types of medication often include obesity, lethargy, and damage to the body, including organ failure.
It is easier for people to respond to those problems by focusing on the superficial aspects. People imagine that just by changing the name of a condition you can exorcise the pain. When I was a student they called such patients 'the mentally ill', then they changed the description to 'the mentally distressed ' and now I have been told to describe such patients as having 'mental health problems.'
However, the important thing is not how you name the condition but how people relate to patients with this condition—and whether they treat them with basic respect and simply listen to what they have to say. The pain of this condition is so profound it can't be altered by tinkering with words or coming up with a different diagnosis.
THE HOMELESS CONNECTION
Now we are witnessing a situation where state institutions are reluctant to even admit patients. This is not just a case of staff shortages and lack of beds but not having the resources to cope with such patients. A lot of doctors also state they do not wish to infringe the 'freedom ' of patients to choose whether to accept medical treatment.
Recent research into the homeless throughout Britain has found that many are suffering from mental health problems. Some are even discharged onto the streets without an address to go to. For instance, a health audit of over 2500 homeless people in England in 2014 discovered a much higher prevalence of mental health issues in the homeless than in the general population. As many as 45% of the homeless have been diagnosed with mental health problems compared to 25% of the general population. In Scotland, in 2019-2020, the state found among 8404 homeless households someone with mental health problems.
The latest government data in Scotland showed that in 2019-2020, as many as 27% of homeless households contained someone with a mental health problem. The figures have more than doubled since 2013 {in 2013/2014 the figure was 13%}.
What is worrying is that those people who are homeless are less likely to take their medication. They often have no secure place to keep it. They often have no place to store medications that require refrigeration. One study found that 63% of the homeless failed to take their medication compared to 18% among the general population. A lot of those homeless people are not getting treatment at all.
In the United States of America this is certainly the case. A study by Markowitz in 2006 found that in past studies in Ohio 27-36% of those discharged from state mental hospitals had become homeless in 6 months. They had just vanished or done 'a convenient disappearing act.' A study in New York found that 38% of those discharged from a state hospital had no known address.
The vast amount of overwhelming research indicates that most people with mental health problems are not 'dangerous' or a 'threat' to people. On the contrary, it is so called 'normal people' who threaten them. They are more vulnerable to being beaten, robbed and assaulted than vice versa. They represent a vulnerable group of people who can easily be deceived.
In Moscow they can often find themselves signing away the rights to their apartment to the black market real estate agents who collude with corrupt social workers. The deal goes that if you hand over your apartment, you receive a bed in a hospital with free medical care!
But is mental illness an actual cause of someone becoming homeless? It is fair to state that this, and other factors also play a prominent role such as lack of state protection, lack of treatment, and the presence of great family conflict. A person can be rendered homeless through a complex number of causes. Last summer, I interviewed a dozen people in Moscow and asked them, “Why do people become homeless?”
An engineer Maiya Yampolskaya told me, "Mental health problems can make people homeless. I heard of a young student who started to become mentally sick and acted strangely when his friends came to visit him. They stopped visiting him. The young man started to neglect himself, stopped washing and then left his flat. He went missing. They found that he had drowned himself in a pond. If only people had understood his condition this might have been avoided!"
A research survey by Nochlezhka (the Russian charity helping homeless persons and others in need) in 2020 found that mental health problems is one of the reasons for homelessness in Russia because such people are often unable to hold or do a job not to mention find a suitable one.
WHAT IS TO BE DONE?
What can be done about these difficult situations? As Jane Hamilton stated, we need far more psychiatric nurses, doctors and available treatment. We also need a stricter accountability such that healthcare staff members cannot just discharge a patient who has no address to go to you. You have to pursue follow up treatment where the patient is at least sent to a homeless unit where he finds a place to stay.
But because of the vast shortages of specialists one does hear of self-styled and unqualified charlatans turning up suddenly to offer their supposed expertise and high-quality services. Jane Hamilton told me, "Once a woman from a crisis center turned up at a Club which helps people with mental health problems and started to tell patients they did not have to take their medication. I got angry. I told this woman it was very irresponsible because if my brother doesn't take his medication his condition gets worse. This woman had no qualifications or real experience at handling people with mental health problems. The club had to ban this person from coming."
Of course, there is a popularly-held notion that patients are better off not taking medication because it is highly harmful and deprives them of freedom. Much of this view gained popularity with the anti-psychiatrist R.D. Laing who thought that prescribed medication should be done away with and the patient should be allowed to just let his psychosis take its own course. His works such as “The Divided Self” {1959} and “The Politics of Experience” {1967} are still bestsellers. The problem is that some people buy those books and go around preaching this message without being aware of the full implications of such views. There have been cases where patients who have not taken their medication can do great harm to themselves and even commit suicide. The best thing you might learn from R.D. Laing is that people have to treat the patient with dignity and respect—this while ignoring his extreme and eccentric views on the medication issue.
ADVICE FOR THE PUBLIC
How should ordinary people react when they encounter patients? Well, we should not be afraid of them and should not be judgmental. I think the best way is to just treat them with respect, be tactful and as pleasant as possible to them. Treat them as equals. Learn to listen to them and ask them “What do you need? What do you want?" The wrong approach would be using a patronizing or paternal approach of "We think we know what is best for you!"
There is an important role which volunteers in certain agencies and clinics can play in assisting people with mental health problems. They can give their time to listen to them, talk to them and befriend them. Those volunteers should have the humility to understand the limitations of their knowledge and experience. That is why it is important they work with the best- trained and experienced staff and ask for any advice. This is because some of those problems are so acute we need to work together.
WHAT CAN WE ALL DO TO HELP?
Helping convince our elected officials of the need for providing help for this part of the population is important not just in Scotland but in many other countries indeed. New programs to better help the patients are needed. More resources like personnel are needed. For homeless persons suffering from mental illness, “a home to go to” is needed. It is through compassion and assistance that we will find a way to help all persons in need.