More on Homelessness and Mental Illness

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.

6 thoughts on “More on Homelessness and Mental Illness

  1. Another brilliant analysis of the serious human problem, homelessness. In the US, we’ve been trying to address the insidious silo mentality with collaboration. I agree that discharge planning is imperative and would only add that the agency/organization that will provide needed support services in the community has to be an integral part of the discharge planning process within the hospital, jail or prison. This promotes a personal bond (therapeutic alliance) between the patient and peer support specialist and caseworker.
    I would only disagree with Dr. Dawson’s comments about addiction. Experience and research support the conclusion that addiction is a genetically vulnerable brain disease that is both precipitated by human behavior and also changes human behavior and bodily functions. Analogous disease/illness processes include food allergies, diabetes, hepatic encephalopathy, etc. We mental health services advocates need to be as effective as addiction care advocacy.

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  2. Again a very good analysis Dr. D.

    Yesterday I went to the Sinclair Annual Lecture, given by yet another young Doc ( 45) on health care policy . Another kick of the can down the road re health care policy.

    i went also to a well attended a Community Foundation delicious luncheon yesterday. Talk by an eminent person on “homelessness.” from Ottawa. A pretty honest and informative talk, but really bandaid as usual. At both I honed in on the serious mental illness part of the equation and stressed the fact that there was no proper intervention at the front end.

    ( Like a safe bed while the stuff is put in place for stabilization and possibly a better future)

    Obvious to anyone that has been observing since the messed up policies proceeded a pace three decades ago, is the need for more impatient beds and a more effective mental health Act.. Much follows from those two things and they are cost effective in the long run. The mess gets worse by the minute and each seriously mentally ill person costs much more money through law enforcement and the justice system and emergency wards. . We advocates press on.

    There were two questions on the neglect of the seriously mentally ill ( Queen” lecture) Euphemisms and wellness stuff abound. Even the virtual hospital came up! All experts no patients on the site!!!!!

    All advice from the expert on line. Imagine that for the trapped in psychosis seriously mentally ill person. The mind boggles the sane. Perhaps we are witnessing 19 84 just a decade or three late.

    I note that Prince William is in the news this morning in the U.S, suggesting that people talk out their troubles on line.

    What about those who can’t appreciate that they are ill and become without their castle? An Englishman’s home is his castle… we were taught.
    William is likeable man, but surely he should observe that the really needy are the seriously mentally ill and that their needs trump the worried well or should do in my opinion.

    The going round in circles get bigger and more tragic by the hour..

    Pollyanna is very uplifting but when it is a serious problem we need a Dorothea DiX to FIX.

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  3. In my experience (17 years mental health RN), at any given time at our local psychiatric hospital in Hamilton, Ontario, 25% to 33% of in-patients were well enough to be in community. They were kept longer to ensure they had their ODSP pension, and/ or appropriate low cost housing. Hospital is a very expensive boarding house. Enormous savings could be made if we stepped up funding/ building geared to income housing for single person units with support staff available 24/7.
    At the beginning of my practice, we were seeing mainly patients who had a major mental illness and who perhaps smoked marijuana. By the time I left in 2018, a large majority of clients were using any illegal drug available, even during hospitalization.
    With good discharge planning, social work doing their job, and community nurses visiting, our clients would still return to hospital within the year in a psychotic state. One thing I never under estimate is the lure of illegal drugs for persons with mental illness. It is very real, and it ensures continued exacerbations of illness for our clients. Sorry to say, drug rehab programs are for the most part ineffective, with high relapse rates — for those who actually try it. They are totally ineffective for people who are not fully committed to staying clean.

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  4. Here in the US our mentally ill loved ones are “stabilized” haha as quickly as possible to free up that psychiatric hospital bed. My son got a big two weeks tune up in one of these general hospital psych wards. I basically had to plead for more time (he would have been discharged after one week) His discharge papers said “Condition: critical. “ Of course there was no plan of action for any sort of treatment, so he continues to go for his monthly shot in the arm and a kick in the ass as he leaves the facility.

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    1. Yes “bed bumping” is totally immoral and unprofessional. I heard of someone (a nurse) who described how a person with a post party psychosis was discharged with very active symptoms to so called homeware. She was very upset about this and obviously knew that it was very inappropriate to discharge a person in such a state.

      One can only imagine what the risks were for the patient ( about to be a client) in doing so? I do not know whether the baby was with the ill person ! Almost certainly a recipe for disaster. There is so much talk of stigma, but what about useful talk about a safe place to be when the person is trapped in very terrorizing symptoms. Clearly to raise the question of care to the policy makers is like shouting in a cave when not a bean counter is listening.

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  5. Why cannot we not go back to the support people had with severe mental illnesses? What the hell is wrong?!!!!
    To: VIVKOTSCH@HOTMAIL.COM
    Subject: [New post] More on Homelessness and Mental Illness

    mross109 posted: “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 housin”

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