More resources are needed to treat mental illness, addiction, and disabilities, a recently retired psychiatrist with the HSE’s adult integrated homeless team in Cork has said.
Dr Maura Duggan made the comments while speaking at a conference by Cork Simon titled Single Adult Homelessness – Who Cares? yesterday.
Dr Duggan explained that the HSE service was set up more than 20 years ago due to “a very clear need for health services, both psychiatric and general medical” amongst people in emergency accommodation.
“These people were not accessing services, so they were continuing to present at emergency departments with chronic conditions,” she said.
She explained that additional resources were needed.
“We originally had an addiction counsellor, and we don’t have one at present. It’s a huge loss to the service”, she said, explaining the importance of having someone “on the ground to make contact and start discussions” with people who were looking to stop substance use.
Factor
Not having an addiction counsellor is despite addiction being a factor in 80% of presentations, she added, adding that homelessness makes problems of addiction and mental health worse.
“We see a marked deterioration in physical and mental health in people since becoming homeless, and they are more likely to escalate substance abuse.”
Dr Duggan explained that, as well as issues with resourcing, “people are already homeless by the time they see us”, so their team are “constrained by context”.
“We cannot treat people for mental health when they are sitting in a tent, actively using substances. To treat people, they have to have their basic needs met.”
In terms of the people they treat, there are usually “layers of complexity”; 63% of them have two different diagnoses, 26% have three or more, and only 11% have just one.
She explained that huge percentages of the people they see have multiple adverse childhood experiences (Aces), which are stressful or traumatic events that happen to a child which can have long-lasting negative effects on their health, behaviour, and wellbeing.
Having four or more Aces increases the risk of alcoholism by 700% and the risk of suicidal ideation by more than 1,200%, she said.
Vulnerability
Dr Duggan explained that, despite their awareness of the heightened vulnerability of the people that they work with “our service is very limited, we have a half-time psychologist so our work is significantly impaired by our resources”.
She also expressed a concern about people with an intellectual or neurological disability, which represents 22% of their presentations, saying that these people most commonly come in contact with their service when they attend emergency services with suicidal ideation, as being homeless with these disabilities is “a very stressful environment”.
Calling for “a very specific response for this group”, she explained that many of these people have not been formally diagnosed, and that the HSE homeless team does not have sufficient resources to provide them with the diagnosis that they need to gain access to disability services.
Another worry Dr Duggan expressed is that, “while the numbers of homeless people have increased, our referrals have not” gone up in line with this.
The majority of their referrals come from emergency departments now, with far fewer coming from GPs, which she suggested could be down to widespread difficulty in finding a GP and being seen by one in-person since the pandemic.
As the overall homelessness figures rise, the homeless population becomes more dispersed, with more people sleeping in the Night Light centre on mattresses on the floor — which was opened to alleviate overcrowding — or in B&Bs.
No access
These people do not have access to a key worker like those in the main emergency accommodation shelters.
“Staffing on the ground has not kept pace with the numbers of homeless that are presenting, and staff do not have the time and resources to build relationships with people” with this level of overcrowding, which in turn could decrease the amount of people they refer to further services,” she said.
She also suggested that homeless people are moving from Cork county to the city.
However, as they are not local to the area, it is harder for them to progress to additional services.
“We have a social worker on our team, which is fantastic, but in order to access the social worker, people have to meet the threshold of a referral to mental health services,” she added.
“Access to a social worker should be considered for the general homeless population.”
Additionally, “access to addiction supports is perhaps not as good as it might have been in the past … and patients rarely make it into specialist services” for eating disorders, ADHD, because of “exclusion criteria” within them.
“There’s a lot of unmet need — we’re skimming the surface.”
Dr Duggan also responded to a question from the audience about whether the closure of many large mental hospitals in Cork and across Ireland has contributed to an increase of people with mental health difficulties who are homeless.
“The closure of large psychiatric hospitals has to be welcomed,” she said. She acknowledged that, while the idea of people moving to community services was a better idea than the more institutional nature of the old facilities, the new model required further resourcing.
Concern
Ireland is currently preparing to replace the Mental Health Acts 2001-2022 with a new mental health bill, but Dr Duggan expressed concern that this could make things worse.
“Unfortunately, funding for community services continues to lag significantly behind,” she said.
“People who have fallen through the cracks often end up homeless or in the criminal justice system, and I have concerns that the new mental health act will lead to further constrain.
“Our inpatient beds are half of the EU average and falling all the time — people are coming out of hospital partially treated. Finding the balance between autonomy and the rights to treatment is tricky, but restraints in terms of bed availability, resources, I think we are likely to see more people who are actively psychotic on the streets.”
Sophie Johnston, Cork Simon Community’s research and communications co-ordinator, opened the conference yesterday.
She spoke about the high level of single adults without a home and the particular difficulties they face in securing them, leading to high levels of long-term homelessness among this cohort.
Cathy Kelleher and Dr Fiona Riordan, contributing authors to the Health Research Board’s bulletin: Deaths among people who were homeless, also spoke at the conference.
The bulletin showed that the majority of deaths of homeless people were among the single adult cohort.
Cork saw the second highest amount of these deaths.
Preventable
Nationally, substance use was involved in the majority of the deaths, described by Ms Kelleher as “premature and preventable” — the median age at the time of death was 41.
Kerry Brennan, Cork Simon’s director of services, spoke about the cyclical nature of criminality and homelessness, highlighting that everything homeless people do is in public.
This leaves them more likely to be arrested for drinking, urinating, sleeping, or having an argument than people who do these same things but within their own home rather than on the street.
Describing prison as a “revolving door”, she said: “People get caught in the exclusion cycle, and it’s very difficult to maintain an exit from the exclusion cycle while homeless — access to stable housing is the key intervention”.
However, “having a conviction in last five years is a serious barrier to social housing,” she said, explaining that once someone has a criminal record, it can become more difficult for them to gain access to local authority housing, despite these people often being among the most in need of somewhere stable to live.
Also in attendance at the meeting was Cork TD and the junior minister at the Department of Housing, Christopher O’Sullivan, who said that the Government is currently finalising its national housing plan, which will aim to reduce the number of households experiencing homelessness as well as time spent in emergency accommodation.
“Part of that will be for single adults. The market has failed to provide housing solutions for that group, so the onus has to fall on the State,” he said.
“No government rep can stand up and say that they’re proud or they stand over the homelessness figures that are going up every month.
“The solutions are just not as easy as we think sometimes, there are so many obstacles and barriers to overcome.”