Community Mental Health Research Paper
Mental Illness and Homelessness
The homeless mentality ill are becoming increasingly visible on the streets. Their needs are complex and far ranging. These are often complicated by sociocultural and gender structures within present mental health services.
Such problems range from the threat of being attacked, difficulty in meeting basic needs such as food and shelter and problems gaining access to mental health services. These factors and many others make reaching this group through existing mental health services particularly difficult. (Bhugra, 1996).
In the case of those individuals who are already homeless it may be useful to look at specific psychosocial interventions that could be used as part of the wider system already discussed. Goodman, (1991), found that two commonly reported symptoms of psychological trauma in homeless persons were social disaffiliation and learned helplessness. (Bowlby, 1973), found that adult-adult relationships provided a sense of existential meaning and self-worth. The inability to fulfil social obligations as a worker or a friend may mean that people lose faith, not only in their ability to care for themselves but also in the willingness of others to help them (Kozol, 1988). This causes mistrust of others and is often compounded by the failings of services and social support networks, and by the attitude of victim blaming held by many in society (Janoff-Bulman and Frieze, 1983).
There is little information available regarding bow the homeless population is able to adapt to the consequences of its situation. (Murray, 1996) undertook an exploratory study to describe the lived experience of homeless mentally ill/drug dependent men.
Two major fears were identified. 1. The fear of being violently physically assaulted and 2. The fear of not being able to meet basic daily needs such as shelter, food and health care. The most difficult aspects of being homeless were identified as frustration with night shelter staff, survival, meeting basic needs and the negative reactions experienced from the general public and healthcare agencies.
(Murray, 1996), Identified the severely mentally ill homeless persons are prone to taking illicit drugs, abusing alcohol and displaying aggressive behavior as a way of coping with their situation. They are more likely to adopt a pessimistic outlook on their future, and feel that the 'listening ear' of the shelter/hostel staff is an ineffective outlet for their psychological trauma. Evidence suggests that as the period of being homeless increases so too does the use of ineffective coping styles and the severity of mental disability (Cohen and Thompson, 1992).
The facilitation of social support groups within hostels may reduce the sense of alienation (Van der Kolk, 1987), promote mutuality and trust and enhance the person's self-esteem, (DiBlasio and Belcher, 1993). Such groups will also increase the support network for people in times of crisis. This will hopefully reduce the risk of the client disengaging from the service. These groups may also be useful for those people recently accommodated and those who use the hostel as a form of social support at a time of transitional change, (Williams and Allen, 1989).
However, not all hostile environments are able to hold such groups. Reasons may be far ranging such as the lack of training for the hostel staff, insufficient numbers of staff to run the groups, or a lack of motivation to hold such groups. Outreach workers may help hostel staff reformulate and modify the care given to users and increase the staffs' sense of what could potentially be achieved, (Williams and Allen, 1989). Outreach workers should attempt to help those people who are not in shelters, but who desire to be, to move into shelters which are situated in their own community so as to promote the maintenance of social relationships. The outreach worker may be able to play a supportive role and rejuvenate social bonds that were problematic when a family or friends were living together. Seeking to raise the community's appreciation of homelessness and mental health issues may also reduce the effects of disaffiliation, (McLean and Leibowitz, 1990).
Mental health services need to embrace the public's attitude towards the mentally ill within society. There is widespread public mistrust of mental health services regarding the effective management of mentally ill patients and the side-effects of available treatments. This has resulted from the paternalistic and coercive elements of the service (Rogers, 1992). Mental health outreach workers need to consider the value of their service in the light of these aspects of psychiatric care and recent legislation.
The supervision register and the implications of the Mental Health (Patients in the Community), (Bill,DoH, 1996) has highlighted users' fears of being pursued and controlled by professionals which may compromise the role of outreach workers as they seek to informally engage and maintain contact with people. Paradoxically, such outreach services may alienate the homeless mentally ill even more, being seen ultimately as a coercive force.
Solomon (1988) describes an outreach service that uses consumer care workers and mental health social workers alongside each other. They act as detached outreach workers and back up a primary healthcare team which visits emergency food shelters. The independence of the outreach workers from the shelter organization and from other mental health agencies meant that the stigma of using the service was lessened and clients were more able to disclose information without fear of dismissal from the shelter.
Outreach workers were more free to spend time building relationships with clients and more able to deal with clients' needs without requiring them to use mental health services. By using a flexible approach to engagement, outreach workers achieved a high level of credibility among clients (Solomon, 1988). Involving consumer case workers who were themselves either severely mentally disabled/ homeless or both proved valuable. Their knowledge of where homeless people congregate and, more importantly, their own personal reputation, makes them an invaluable resource group in caring for the homeless mentally ill.
Considerable training, supervision and flexibility was necessary to match the homeless workers' role, tasks and abilities with current mental Health services. An additional problem was that they did not command the respect of other agencies and, as a result, were treated poorly which caused them much distress. Generally, the case workers gained a lot from their role by learning social skills and work habits which they developed by working alongside the outreach workers. This circumstantial presentation suggests how a range of outreach approaches could be devised to suit statutory and voluntary agencies. The expertise of both should be available to the client in the least threatening way possible to enable the client to form a positive engagement with the service.