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November 27, 2011

Homelessness and Health

Reuel S. Amdur

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Healthcare Conferences Canada held a conference in Ottawa November 18, looking at "Cultural Diversity & Mental Illness." One would expect such a conference to focus on issues relating to immigrant groups and Aboriginals, and it did. However, it also looked at homelessness and mental illness. The underclass that includes the homeless is part of a subculture or counterculture that overlaps with both the wider culture and with a criminal subculture. Mental health is a serious concern in this milieu.

According to University of Toronto Professor Joseph Chandrakanthan, over 60% of incarcerated youth have a diagnosis of mental illness and substance abuse.  Yet, “There is no mental health treatment available.”  Psychology Professor Manal Giurguis Younger, of St. Paul University in Ottawa, addressed a variety of issues related to the homeless.  She noted that rates of mental illness among the homeless, while varying from study to study (and no doubt from city to city), could be as high as 60%, if we include substance abuse, and “addiction issues often combined with other mental illness as well as physical issues.”

She spoke of the deinstitutionalization movement of the 1970's.  At the time, she found conditions for the mentally ill in hospitals to be “filled with sadness,” leaving patients with no choices.  Deinstitutionalization was meant to reduce dependency, normalize and improve quality of life, and create long-term community support systems.  According to Younger, implementation was difficult, resulting in many of the mentally ill becoming homeless.

There is a slightly different perspective that can be taken to the situation.  Yes, hospitals were closed, but the services in the community were inadequate.  The governments saved money at the expense of the mentally ill–cheaper to use shelters without expensive personnel than hospitals with psychiatrists, nurses, etc.  Then, many of them ended in jail for petty crimes, where also they received no treatment.

Her report that “Mental illness is reported to increase the risk of being homeless by 10 to 20 times” is no surprise.  So what needs to be done?  Supportive living, if it has the necessary authority, can intervene to insure that the person’s money is spent on rent, to avoid eviction.  It can assist in many other ways.  A key issue is the ongoing lack of adequate mental health manpower in the community to provide the help needed.

Popular now is the Housing First approach.  Give the homeless a place to live and add treatment and social services once they are placed.  The issue of adequate manpower resources remains, however.  And some people refuse the offered mental health services and end up back on the street because of their illness.

While mental illness increases the chance of being homeless, it also works the other way around.  Take a young person fleeing an impossible home situation and ending up on the street.  “If someone is living on the street, in three weeks, the traumas endured can cause permanent personality changes.”  The person may end up with a personality disorder and a lack of ability to trust.

Younger looked at issues of emergency care and end-of-life care.  If a homeless person arrives in a hospital emergency room with a physical condition involving pain, the staff have a difficult time in determining the amount of pain medication to give, as usually they will not know the person’s drug abuse history.  If the person is a heavy user, then a normal dose will not suffice.  If not, a high dose may be dangerous.  Outside the hospital setting, medical care for a street person becomes problematic because they often don’t have the medical insurance card.  Street people regularly lose all identification, medical insurance cards, birth certificates, etc.  Sometimes they sell them.

Street people die young, usually in their 40's.  In their final days, some need hospice care, but appropriate care is scarce.  Regular hospices are ordinarily full, and in any case they may not be suitable for street people.  For example, the people may have substance abuse problems that most hospices are not set up to deal with, and they may have street friends visiting whom a middle-class kind of hospice would find disruptive.  Street people in hospice settings do not necessarily stay put.  They are apt to wander around, come and go. 

Thus, hospices for the homeless are needed.  As far as issues of substance abuse are concerned, “cure” or abstinence is hardly the solution for their end-of-life situation. The harm reduction approach fits better.  Rather than cutting off all liquor, hand out controlled amounts over a period of time.

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