By Dr David Laing Dawson
With seemingly intractable social/medical problems we tend to rant about them or offer sweeping, global, feel better (they make us feel better) but useless proposals such as “talk about it” for suicide, and more affordable housing or shelters for homelessness.
And we forget history.
In the seventies our community psychiatry teams (at least the ones I was involved with) made home visits, ensured patients stayed on their medication, intervened with landlords, and one team member was official liaison with all, what was then called, second level lodging homes.
In the eighties our Psychiatric Hospital formed a special team to help prepare patients for discharge and settle them in appropriate housing, and connect them with all the treatment and support they would need.
And this is the moment to intervene and to focus resources: preparation for discharge. Discharge from hospital, addiction treatment centers, and from jail. This is the moment to spend resources and money, finding, securing, settling in with all necessary supports. And those supports can include intervening with landlords, attendance at AA daily, a sponsor, a visiting nurse with anti psychotic medication in a syringe, community treatment orders, help with shopping, budgeting, ADL’s, peer support etc.
Many factors have combined to produce the current problem: loss of low skill jobs, epidemic of opioid addiction, lack of affordable housing, psychiatric treatment shifting to short stay general Hospital treatment and specialty outpatient clinics, and a well-intended but damaging shift to protection of individual rights at any and all cost, and an institutionalized denial of mental illness combined with a paradoxical acceptance of addiction being an “illness”.
(in this strange world of ours a man who believed he was born of the stars and a professor was deemed by the Supreme Court of Canada to be competent to refuse treatment though it meant he would be incarcerated the rest of his life, and another court reinstated a nurse who stole opioids from her patients to feed her addiction on the grounds that “her addiction was an illness”
Emergency shelters, delivering blankets and food to the homeless, clean injection sights, mental health teams working with the police, street homeless watch, a differently designed clothing donation box are all worthwhile band aids but if we want to actually make a difference over a long period of time we need to focus resources to help people through that difficult transition from hospital, treatment center, or jail into a settled housed life within a community including all necessary support to remain housed and stay on the medication that prevents depression, psychosis, or mania.
Some years ago while giving a talk in The Netherlands about treating “borderline personality disorder” I was told it was illegal for Dutch hospitals to discharge someone to the street. I don’t know the details of that illegality, and it is a bit extreme for our social contract in Canada, but we certainly could keep patients in hospital a little longer while a special team ensured successful housing and compliance with treatment post discharge.