Friday November 17, 2017

More than a Bowl of Soup

I love Thanksgiving. I love the colors of fall, the crisp air and blue skies, and the Macy’s Day Parade – for which I will be a garden gnome this year in case you are watching!  I love that it is always on a Thursday, turning a workday into a holiday into a long-weekend every year. I love the coming home of the kids, the kvelling of the grandparents, and the catching up with family and friends.

I am also aware that as we delight in a never-ending spread of turkey and trimmings, those without homes often line up at soup kitchens for their Thanksgiving meal. Among those in line are many individuals with mental illness.  In fact, as many as 70% of people in line for meals at soup kitchens also have mental health needs.

soup kitchen 2

Homelessness + mental illness = trouble. Unless the mental health services are brought to the homeless. This is just what Whitfield Street Soup Kitchen in London has in mind. They are planning a first-of-its-kind professional drop-in mental health service, so that regulars at the soup kitchen can receive no-strings-attached help in the same place where they get their meals. While this may all seem like a no-brainer, there are multiple reasons why getting mental health care to this population is difficult, and why services like this are so necessary.

1.

Homelessness and mental illness goes way back.   Policy analysts suggest that to really understand the problem of homelessness and mental illness in the US, you have to start with the 1960s deinstitutionalization and community mental health movement – the well-meaning policy begun by President John F. Kennedy that was meant to help get people with serious mental illness out of overpopulated mental institutions characterized by egregious rights violations. The idea was that they would be better served through more integrated programs in the community. Lack of funding precluded the last half of the plan and left many with severe mental illness with nowhere to go but the streets. This lack of funding for community mental health services is still with us today – here in the US, and in many parts of the world, including the UK.

2.

Mental Health services are complex to navigate. Maybe due to the lack of resources put toward developing community mental health services for people with severe mental illness, the way that mental health services are set up doesn’t make it easy for the homeless to access. Lack of after-hours services, lack of coordinated care, lack of stable shelter, and high levels of exclusion criteria for service use are some of the challenges.

 

3.

Catch 22. Where social services do exist and when individuals who are homeless are able to navigate the system, if their mental illness goes untreated, the same mental health problems that contribute to homelessness also conspire to interfere with successfully using the social services available. From psychotic symptoms that interfere with rational planning to lack of trust related to a history of abusive relationships and trauma, individuals with mental illness who are also homeless have a complex range of issues that need particular understanding and attention.

 

4.

Gender matters. While the majority of those who access services for the homeless are men, women make up at least a quarter of that population. But services available to the homeless that were generally developed by and for men often don’t take into account the unique needs of women. Mixed gender hostels, lack of women service workers, and staff untrained in trauma (particularly sexual assault), and lack of care for children, can leave women with few options.

 

5.

Civil rights – benevolent care? AOT (assisted outpatient treatment) varies by state in terms of how much a person can actually be coerced into complying with treatment for a severe mental illness. Advocates claim that, in certain situations, mandated treatment is in everyone’s best interest. Critics disagree – claiming it is an intrusion of privacy and a human rights violation. Both sides have valid points, and constructive dialogue may actually help us move forward with policy that saves lives and preserves dignity. More on this another time.

Kathleen M. Pike, PhD - Is Professor of Psychology & Director of the Mental Health Program at CUMC kmp2@cumc.columbia.edu