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Mental Health and Homelessness

Earlier this week I wrote a post about a mentally ill homeless woman in Westboro. Several commenters and I mulled over how she could best be helped. (Followed, sadly, by another commenter who declared the woman to be a crazy bitch who should be overpowered and locked up forever.)

Coincidentally, two days later, The Canadian Institute for Health Information (CIHI) released a new report called Mental Health and Homelessness, which is freely available online.

I think it’s a little disappointing that this report takes the approach of individualizing homelessless, and virtually ignores its structural causes, such as poverty. Nor does it get into the recent regression of housing policy in this country, such as the dismantling of our national housing strategy in 1993.

That being said, it was still an interesting read and it does provide a useful overview of the issues. If you don’t feel like reading the whole report, here are some of the main points.

Pathways to Homelessness

People who are homeless are more likely to experience mental illness. In some cases, the mental illness may have been a factor in them becoming homeless. In other cases, the homelessness may have been a factor in them experiencing mental health problems. Mental illness can become worse with continued homelessness.

Unhealthy streets

People who don’t have homes are more likely to suffer a variety of physical health problems too, including respiratory infections, arthritis, infectious diseases such as tuberculosis and HIV, skin and foot problems, poor dental health, injuries and poor management of chronic conditions such as diabetes.

People who don’t have homes die younger than people who do. One study showed that half of homeless women in Toronto died before their 40th birthday.

Homeless people tend to be subjected to more stress than people who have homes, and are more likely to have low self-esteem and insufficient social supports.

Suicide attempts and suicidal thoughts are more common among homeless youth than those who have homes. (In Ottawa, 4% of non-homeless male youth and 21% of homeless male youth report at least one past suicide attempt.)

Mental Illness

There are higher rates of schizophrenia among the homeless population than in the general population. Less than 1% of the population reports having been professionally diagnosed with schizophrenia. Equivalent data is not available for the homeless population. However, in Toronto, 6% of 300 shelter users surveyed reported a psychotic disorder, primarily schizophrenia.

In 2002, a street needs assessment project was undertaken in Ottawa, and 80 homeless people who do not use shelters were interviewed. Of these, 33% said they have mental health concerns (20% depression, 6% anxiety disorders, 4% schizophrenia and 3% personality disorders.)

Toronto’s Pathways into Homelessness Project found that 29% of shelter users met the criteria for anti-social personality disorder, often in combination with other diagnoses such as depression or post-traumatic stress disorder.

Substance Abuse

Rates of substance abuse are higher among the homeless population.

Some people have both substance abuse disorders and mental illness diagnoses (‘concurrent disorders’). Homeless people with concurrent disorders are likely to remain homeless longer than people with just one disorder.

Depression

Depression is more common among homeless people than people who have homes.

One-third of Ottawa’s adult street people report mental health problems; of these, 20% report depression.

In Kitchener-Waterloo, almost half of the street youth in a study reported a decrease in their depression since leaving home; 28% reported an increase.

Barriers to Getting Help

Some of the barriers identified by Los Angeles street youth who felt they needed help but didn’t get it:

  • not knowing where or what services to use (53%)
  • embarassment (47%)
  • money (36%)
  • fears the service provider would contact family (36%)
  • fears the service provider would contact police or social worker (36%)
  • thinking the service would not help (33%)
  • Emergency Departments

    Mental health and behavioural disorders is the most common reason for Emergency Department visits by the homeless (35%).

    The #1 reason for inpatient hospitalization of the homeless is mental diseases and disorders (52%), followed by significant trauma (7%). That’s a huge gap between the most common reason and the second most common reason.

    Policy and Programs

    History

    In the 1800s, the mentally ill were often warehoused in prisons or poorhouses. By the end of the century, asylums were developing.

    Starting in the 1960s, psychiatric patients were being discharged into the community when there wasn’t room for them in the hospitals. This move towards deinsitutionalization was prompted by several factors: economic contraints, human rights, and pharmaceutical improvements.

    Community mental health services did not increase at the same rate that patients were being released into the community.

    Current and future developments

    In 2006, a Senate report recommended establishing a Canadian Mental Health Commission and a national mental health strategy [and Harper announced its establishment just this Friday.] The report noted that affordable housing is a key issue. It said that the percentage of people with mental illness who need access to housing is double that of those who do not have mental illnesses.

    Two housing models

    Continuum of Care Models (Treatment First)

    Three stages: outreach, treatment, housing. Essentially the housing is offered as a reward for the successful completion of the psychiatric or substance abuse treatment.

    Housing First Models*
    The homeless and mentally ill are offered housing that is not contingent on treatment or sobriety. They tend towards harm reduction approaches rather than abstinence. Other community services are offered but are not compulsory.

    Outcomes

    American research indicates that participants in the Housing First model remain housed much longer than participants in the Treatment First mode (5 years later: 88% vs 47%). Another study found that homeless participants with a major mental illness such as schizophrenia or bipolar disorder who were in the Housing First program spent more time in stable housing and less time in hospitals than their counterparts in the Treatment First programs.

    Existing programs are typically only able to serve a small number of the homeless, despite large numbers of homeless people across Canada.


    *My note: The Housing First Model may not be as appealing as it might first appear. It’s actually being widely promoted here in Canada by Bush’s Housing Czar, Philip Mangano. It’s deceptively simple, and it’s also just plain deceptive, as in the US it’s accompanied by deep slashes to social housing budgets, along with punitive crackdowns on the homeless, such as legislating them out of the downtown core and introducing laws against feeding them. For more information, see Cathy Crowe’s newsletter, or this Wellsley Institute backgrounder by Michael Shapcott, or this article in the Toronto Star.

    However, it could be reasonably argued that this is not a failing of the model itself, but of the way it’s being implemented in the US. Maybe this model – combined with a respectful and pragmatic attitude towards people who are mentally ill and homeless – could help meet the Westboro woman’s needs.

    5 comments to Mental Health and Homelessness

    • Hi Zoom, I caught Bill
      Dunphy’s plug of your blog on his blog that also promoted my blog ;-)

      I would like to answer on a few of the topics raised in this post – but have done so in part – on my blog months ago and will address the announcement of the new Mental Health Commission shortly there.

      I want to start by asking a few questions that you don’t have to answer, it’s only for you to think about.

      Have you ever been homeless? Has a doctor ever denied you medical services because of a perceived illness? Has a crime ever been committed against you because of your difference – mainly because you have a disability? Have you been denied a legal right because of that disability?

      The following is a parable – a compilation of scenarios that begs the question, how would you react? For the most part, the scenarios are hypothetical, but are not far from the Ontario mental health abuse system reality. The parable is to illustrate the concept of what it’s like to have a mental illness or to be a normal human being with normal human reactions such as anger and frustration but those normal human emotions are used to describe symptoms of serious mental illness as if they were consistent and persistent states over a lifetime, not just situational.

      In other words, it’s a lesson on how to drive a person mad.

      Are you able to remember a time when you learned of the worst news you ever had in your life (to date)? Do you remember the anxiety you felt? Now allow yourself to imagine that you felt like that 24 hours a day for about 2 weeks, for example.

      What if you had more bad news on top of the bad news you already had?

      What if a person – someone you trusted – learned of your bad news and then deliberately did something to you to add more bad news on top the bad news your already trying to deal with?

      Let’s say a person of trust tells you your house just burned down and you had no money to get a hotel room or rent an apartment. This person of trust tells you they weren’t willing to give a place to stay for the night either and you were too upset to drive. As a result you were forced to stay overnight with some criminals who were stealing other people’s property.

      You found out later that your house didn’t burn down and the person of trust didn’t have any reason to justify saying it other than they did it because they could get away with it.

      How do you think you would react to that person?

      Imagine that you react to that person of trust by stating how cruel they were and was visible upset like crying. Then, lets say, you get in your car and drive to a store pick up a television set, a computer and a VCR that you paid for and own.

      You put the stuff in your car and go to drive it away but the cops come and say your trespassing on private property because the person of trust told them you were without justification or reasonable rationale. They have misused the ‘safety’ concern as a reason to deny you shelter not because there was a justifiable safety concern.

      Then the person of trust won’t let you have your car or your property because they say, the car is on their property and you don’t have a right to it.

      The cop lets them keep your property and the cop takes you away even though you protest and your stuff is kept against your will. That person of trust says you can have your stuff back “the next day”. The cop says to trust the person of trust.

      The “next day” you get your car back but some property inside is missing. The person who you trusted, including the police officer just manipulated your fears and anxieties and make your fears and anxieties come true.

      How do you think you would feel? How do you think you would react towards that person of trust? Do you think your loosing your mind? Do you think you have a mental illness? Do you believe those who tell you have a mental illness? Do you believe that it’s as serious as they say it is?

      Let’s say you reacted to that person of trust and you left their presence. Let’s say your reaction included tearing up a paper pamphlet and throwing a water bottle, hardly a threat of violence considering the circumstances. In order to get to your car, you have to walk over to a priest’s house because that’s where you parked it.

      You find out that person of trust called the priest and told them you were mentally ill and that you were not safe. You don’t know what this person of trust said to the priest, just how “unsafe” you were. What does that mean, “unsafe”? Did they follow the legal criteria to make that judgment or was it hysteria?

      It must have been pretty bad because the priest took the remaining property you had AND your car and wouldn’t give them back against your protests and demands.

      How would you feel? How do you think you would react? Do you think your crazy? Do you think these persons of trust were trying to drive you crazy or do you think they were trying to help you?

      Examine how you would really feel if you were being told lies, how you would feel if someone took your property without justification or colour of right. We would normally call it theft but because your perceived to have a mental illness, personal property laws don’t apply to you.

      How would you feel, lets say, if your boss came to you and made an accusation about you because another coworker told them. You ask to see your employee records but the HR person hides the document indicating the accusation in another part of your file. You later find the record and ask your boss why this coworker made the accusation without justification and the boss believed them without evidence.

      Now lets say your boss got this information from the Priest who got it from the person of trust. You make a complaint to the Priest’s Bishop to see what records they have and WHY a priest has information about your medical condition.

      When they let you see some records it documents that you have schizophrenia, for example, or borderline personality disorder, but you have never in your life been diagnosed with it – and your 45 years old.

      You found out that the person of trust told the priest something about the perceptions of this illness you never knew you had, the priest acted on it and his Bishop acted on it.

      You want to know what they were told and were telling others without your consent or knowledge for example, but they refuse to tell you. You know your “medical condition” (whatever it was stated to be) was passed verbally and perhaps its written somewhere – but your not allowed to see it.

      You go to the government agency responsible for allowing you access to your own documents and medical records, you provide hard evidence and dates but they tell you didn’t provide them. They didn’t read your submission otherwise they would have seen the documents proving your position.

      You tell them there is a Supreme Court decision that says you have to have all notes and documents that make up medical records and your told by the government agency that they don’t have to follow Supreme Court decisions on what constitutes medical records. They have just admitted they are above the law, and you are not covered by it.

      You wonder what is happening to your mind. You try to find a lawyer but they hate persons with mental illness yet you have never had any hospitalizations for mental illness in the past.

      Even though you try your best not to mention “mental illness”, it has already circulated through the medical system like a runaway train and any mention of the ‘mental health act’ will cause the lawyer to abandon you.

      Even though you don’t have these illnesses, your denied medical treatment because of the perceptions of these illnesses by doctors. If you react, the doctor will automatically assume your exhibiting these symptoms and thus “judge” you to have a mental illness. Your denied work for your presumed disability. The Ontario Human Rights Commission ignores persons with mental illness and uses it against you. The Ministry of Labour and the Labour Board ignores your legal rights. Unions keep you from getting work and they want to limit your usefulness.

      Your almost convinced that you really are crazy and your sensitive to how your reactions to things might be perceived – whether those natural human reactions are justified or not. You know that treatment like this is not the same everywhere – just in some regions of Ontario – like Hamilton for example.

      You have all the hard evidence, you have witnesses, you’ve even become learned in the law – but lawyers won’t take your case and some even tell you the legislation you just read or the rights you know you have, are not available to you because you are “mentally ill” and the courts don’t judge in your favor because you are “mentally ill”. Because you are mentally ill lawyers won’t give you legal counsel.

      Not even legal aid will cover legal counsel for Charter challenges or other civil matters. They will only cover you if you did something criminal.

      You read and watch – as some members of the media create monsters of those who really do happen to be mentally ill and haven’t been treated (or have been denied treatment) until the point they harm someone.

      You learn that the majority of homeless persons are mentally ill. You learn that the majority of homeless go to hospital because of mental health symptoms.

      But what you don’t learn is WHY that person is mentally ill.

      You ask yourself – how many of these people actually have been born with a serious mental illness and how many of those mentally ill have had the system CREATE the mental illness?

      With the parable in mind – are you able to ask the hard questions of those who are in positions of trust and power?

      You may be appalled to learn that the parable is based on a true story, with some of the facts changed to better illustrate with similes in order for a person who hasn’t experienced the mental health abuse system in Ontario.

      The important concept to understand is that a person’s vulnerability was exploited and cruelly victimized by those individuals who are in actual positions of trust.

      The facts may not be the same but the concept is true. The theft because of mental illness is true, the making of homelessness because of mental illness is true, the denial of medical services because of mental illness is true, the denial of equal protection and benefit of health and privacy laws because of mental illness is true, the denial of legal services is true, the denial of political representation because of mental illness is true.

      Particular actions by persons of trust have abused the very individuals they are supposed to be protecting. Those actions have contributed in aggravate serious mental illness when it didn’t have to.

      Many of those persons of trust are doctors, nurses, shelter workers, bureaucrats, lawyers, police officers, CAS workers and politicians.

      If persons considered mentally ill were asked how they were treated by doctor’s and nurses in Ontario’s hospitals, I’m sure a dismal picture would be gleaned.

      Perhaps dismal stats of how many patients got worse instead of better would be enough to jar the Minister of Health and Long Term care to admit that in parts of Ontario’s system it represents some of the worst of our society as cruel and unusual treatment is status quo.

      I’d love to see statistics on these questions:

      How many persons who are considered mentally ill were denied medical services by doctors in hospitals because of their mental illness? How many doctors have denied these patient’s their wishes for treatment?

      How many persons considered mentally ill, because of a physician’s discriminatory practice of ignoring physical signs of illness assuming it’s a symptom of a person’s perceived mental illness, allows them to die?

      How many persons are denied primary care by physicians because of their perceived mental illness?

      How many bureaucrats deny the guaranteed right of equal protection and equal benefit of the law to persons who are perceived as having a mental illness?

      How many politicians ignore the deaths of persons who have mental illness because of criminal negligence by the people who are legislated to take care of them?

      How many police officers are complicit in criminal acts that deprive persons with perceived mental illness from their own property while they were in states of vulnerability?

      How many lawyers sit by and watch these deaths, the outright abuse of legal rights and think this is protecting the law?

      Answers to any of those questions are going to reveal that persons with diagnosed mental illness probably don’t HAVE to be mentally ill because their illness was either compounded by an unjust system or it was created by a discriminatory and unjust system.

      Once the actual systemic causes are addressed and rectified and patients compensated, I believe the incidences of mental illness will decline

      Once there are actual tests that confirm whether or not a bona fide mental illness exists and the 300 + DSM stats of mental illness “symptoms” are proved to be dogma of pharmaceutical companies and their researchers (how many of these symptoms exist because of power of suggestion?)in universities and hospitals, doctors, nurses, lawyers, police forces and politicians will then stop taking advantage of this vulnerable group of people.

      They only do so now because they CAN.

    • Hi Marlene – I just wanted to let you know I’m not ignoring your comment. I’m just taking some time to think about it before responding. – zoom

    • Marlene, I haven’t finished thinking about this, but I have a couple of thoughts to share with you at this point.

      Some of what you’re suggesting sounds like something straight out of “One Flew Over the Cuckoo’s Nest,” which I think, at the time, made many of us contemplate what it would be like to be falsely labelled as mentally ill and then have that label used against us by people in power. I imagine it would be horrifying and frustrating and quite possibly even madness-inducing.

      And I’ll grant you, it probably happens.

      But I don’t think there are all that many “Nurse Ratshits” around, and why would the majority of doctors, nurses, lawyers, police and politicians have any interest in taking advantage of mentally ill people, or driving sane people mad? What would be their motive?

      You say they do it because they CAN, but I’m not convinced by that.

      I do, however, agree wholeheartedly with you on some points. I think it’s clearly in the pharmaceutical industry’s interests to label normal behaviours deviant.

      Anyway, thanks very much for reading, and for the long and thoughtful comments.

      – zoom

    • I assume you get comments even from old posts? If so, here’s another interesting article:
      http://www.nytimes.com/2006/07/05/us/05homeless.html

    • in third world countries, mental health is never a priority.:-`