Psychiatric Homelessness Seminar
National Council of Women Queensland Branch
A seminar on Psychiatric Homelessness was held in Brisbane on 11th August 2005, convened by the National Council of Women Queensland Branch. The issue was Psychiatric Homelessness. I have some first hand dealings with this issue, over many years in various positions, and was invited to be a key speaker.
First the president of the Schizophrenia Fellowship spoke. He put forward the institute’s position that institutionalisation had failed, along with he agencies charged with implementing institutionalisation. He also put forward that the Commonwealth Government must exercise accountability of the funds it provides for help to the psychiatric homeless. State agencies must also change their policies. There is also a tendency for departments to deny their responsibilities, and refer to other departments.
The Fellowship also held that psychiatric disabilities are different from physical disabilities. Physical disabilities are constant. The symptoms, signs and treatments are predictable. Psychiatric disabilities are variable, and sometimes impossible to predict. Treatment, therefore, is also variable, and medium to long term prediction of treatment impractical.
At this stage, I thought of governmental policy that disability pension can only be granted if a psychiatrist guarantees treatment will take more than two years, and describes the treatment intended for at least that period. In view of the nature of these illnesses, psychiatrists are reluctant to do so. Therefore, those suffering psychiatric illness are unfairly denied disability pension, simply because their disability isn’t physical.
I was the second speaker, and conveyed my own stories of psychiatric illness and lack of treatment available, not just in Queensland, but nationally. This may form the basis of a separate report, but I will not convey them here, as they detract from more serious cases that were brought up by people with far more pressing concerns.
After I had related my story, a mother from the Association of Relatives and Friends of the Mentally Ill (ARAFMI) told of her struggle of more than a decade with her son’s illness. As she spoke, I was sure I knew the man she spoke of – the man who walks the streets of Brisbane all day, speaking to no one. Everyone in the city has seen him, but know little or nothing of him. Now I was hearing his story.
He had begun having hallucinations at 19. There were voices, imaginary people, imaginary objects. Real to him, but invisible to others. At various times, he wanted to be like Martin Bryant, the mass murderer who killed 35 people one day at Port Arthur. He believed he was God, and his mother the devil. He spoke of killing her. His behaviour became increasingly irrational. Eventually, he was admitted to Princess Alexandria Hospital, in Brisbane, because of public concern over his actions.
Princess Alexandria Hospital could find absolutely no evidence of any psychiatric problem, and promptly discharged him. Less than a week later, a private psychiatrist diagnosed him with antisocial personality disorder, and catatonic schizophrenia. Now living on the streets, he is homeless, and not taking medication. His mother meets him each Thursday, but is concerned. He has stopped showering before these meetings, apparently denied access to the public showers supplied free to travellers at Roma Street railway station. The reason for this is unclear. Maybe they don’t want dirty, smelly people using the showers…
Fourth on the agenda was another mother from ARAFMI. Her daughter had become delusional, and claimed everyone was stealing from her. She spoke of nightmares while awake, apparently the only way she could describe the hallucinations she was having. Maybe this is a reflection of how horrific these hallucinations are to hose that suffer from them – nightmares.
The daughter had become totally delusional and psychotic. She had gone off her medication. The mother, in desperation, had called the mental health support team. They said they could only come out if the psychotic and delusional person freely agreed to them helping her. I’m a short, fat, blonde male from Canberra. Even I could see how ridiculous such a policy is.
An observation she made at the beginning of her tale was quite apt. Once, the psychiatrically ill were kept in hospitals. There was no freedom, but lots of care. Now, there are virtually no psychiatric hospitals. The patients have lots of freedom, but little care. They need lots of both.
The fifth speaker was another member of the Schizophrenia Fellowship. She spoke of the problems of the psychiatric homeless ending up in gaol. Her son was in this category. Prisons are the new asylums. She recognises, as I suppose we all do, that this is a grave injustice, but it is the only place available. My reflection: are prison officers adequately trained to deal with the mentally ill? From personal experience, both sides of the law, no they aren’t. The nature of law enforcement, at present, denies the possibility of this happening.
She went on put her position that deinstitutionalisation, American style, has been a sensational flop all over the world. Sprinkling the mentally ill throughout society, and hoping their needs will be miraculously met… Oh, by the way. The Australian Bureau of Statistics (ABS) report that about one third of all homeless suffer mental illness.
These parents, their spouses, their other children, their friends… how many people suffer because “the system” fails the psychiatric homeless? What do we do about it?
A flash of light and a clap of thunder, and the government representatives appear. I will apologise in advance. I have a preconditioned scepticism about government people.
First, a woman from Queensland Housing spoke. She seemed to know what she was talking about, and spoke of the levels of homelessness, and the urgency with which each of these levels needed to be addressed. I was a little surprised that emotion was actually coming from a government representative. I was further impressed when she stated, with seeming genuine honesty, that government departments needed to talk to each other. Maybe she was a genuine crusader, maybe just naïve. I hope the former is the case.
Next, a woman from Queensland Health. She spoke of an integrated system that was to be introduced. 235 million dollars had been allocated, including 45 million dollars for housing. A transitional housing program would be implemented, and after six months, the acutely disadvantaged could successfully be placed in hostels and boarding houses. OK. My hopes have dropped, and I feel my scepticism have been justified. There seems nothing new from the Health Department.
These were the main points as I remember them. I leave it to the reader to ponder the stories and points set out, and to submit observations as to shortcomings in the system, and possible solutions.
The seminar now being finished, the points raised need to be considered. I offer the following as my own personal observations of the plight of the psychiatric homeless, and perhaps the homeless in general.
There is a lack of services for people with psychiatric problems. There are a lack of beds in psych wards. There are a lack of carers and community workers. I know of more than one case of a psychiatrically ill person being placed in a share accommodation situation. The carer is then withdrawn, with the justification that the new housemates should take on the role, free of charge
Untrained, or inadequately trained, people are dealing with the psychiatric homeless. These include social security, housing, hostels, emergency accommodation, welfare agencies and prisons. Justification usually comes with such statements as “we’re just doing our job” or “we’re just volunteers.” When people minimalise themselves with the word “just,” it is generally a sign of low self esteem. A further sign of low self esteem is the need to control others. The question arises “how can a person of low self esteem motivate others?”
They can’t. Higher levels of training need to be done for those who work with the psychiatrically ill. Meaningful and effective training, not the pretend training that goes on at the moment. Unmotivated people cannot motivate others.
Abraham Maslow, in 1962, presented the humanistic approach of motivation. He identified six levels of needs: physiological (food, oxygen, water); security and safety (housing, shelter); love and feelings of belonging; esteem (competence, prestige, acceptance); self-fulfilment; and curiosity (need to understand). An individual needs to satisfy the lower level needs (primary needs – physiological; security & safety)) before being able to progress to the higher levels (secondary needs).
Motivation is needed to fully satisfy each of these needs. The needs must be satisfied by the individual, not by others. As example, an individual needs to know that food and water are available in the foreseeable future. If there is uncertainty, from day to day, as to whether food and water will be available, then the most basic level of motivation has not been satisfied. If an individual has to apply most of his time to seeking food, on a day to day basis, little time is left for seeking housing or permanent shelter. Similarly, if food and water are simply supplied, then motivation for self supply of this need is not satisfied.
A personal observation here. One of the simplest and most effective practices I have seen for helping the unmotivated fulfil these basic needs is selling the Big Issue, and other “street publications.” It is a simple, yet constructive way of earning money without being controlled by anyone. The flexibility of employment allows for the basic needs to be satisfied, while allowing time for secondary (higher) needs to be pursued.
However, a quandary now arises. If the primary needs of the homeless are met, then there is no need for the “assistance” or “provider” organisations. If they are not needed, then their own satisfaction of basic needs is placed under threat. With this threat in mind, a culture of actively frustrating the humanistic (motivation) approach to the psychological needs of the psychiatric homeless appears to have developed.
In it’s place, the organisational culture has regressed to an earlier, and outdated, phase of behaviourism. These ideas were developed some 50 years earlier, in the early 20th century, by John B. Watson, and made famous by Ivan P. Pavlov (Pavlov’s Dog experiment). It emphasised: strict procedures; expected responses; and controlled environment. Positive and negative reinforcement, and punishment, were the key stimuli in the early stages of this model. Similar to social security’s stance of “if you don’t do exactly as we tell you, we’ll punish you by not giving you any more money.”
A modern concept of behaviourism has evolved with the emergence of the humanistic approaches of Maslow, and motivation. Most importantly, the mechanical concept of stimuli and responses has been superceded. In its place is a functional meaningfulness of stimulating conditions to the individual. The bureaucratic policies of “one rule for all” do not fit this modern concept. They are more akin to B. F. Skinner’s behaviouristic conditioning and reinforcement, popular during World War II. Guess which country and which political party adopted them wholeheartedly. Do we really need a return to the mentalities that existed during that period of time?
Behaviourism, and Freud’s earlier model of psychoanalysis, are rigidly theoretical, and concerned with illness. They are particularly based on conflict. Many of the organisations who have regressed to these concepts have successfully corrupted it even further. When organisations outside their control employ motivation to diminish conflict, the “corrupted” behaviouristic organisations can only survive by creating conflict, where conflict did not previously exist.
When the psychiatrically ill are subjected to such stresses on their emotions, the existing illnesses are compounded by confusion. It would be expected by any normal thinking person that such conflictual behaviour to any person would result in retaliation. Aggressive behaviour is seen as threatening to most people, and most people respond in kind. A basic survival response. Psychiatrically ill tend to feel threatened more, and are more vulnerable to the aggression aimed at them. The threat is at their ability to satisfy their motivational needs.
If they retaliate with aggression, or even with verbal resistance, they are automatically branded as abusive, and, invariably, the police are called. Mission achieved! Another loony off the streets! Let’s all pat ourselves on the back for a job well done!
The reality is, these behaviouristic people do not even realise the psychological processes they are employing, or the psychological processes employed against them. They ARE simply doing their jobs, without actually knowing why or how. They really don’t have any concept of the consequences of their actions against their clientele. Especially against the psychiatric ill and the homeless.
They are simply doing as they are told. Just as they expect their clients to do as they are told. In this respect, the members of the behaviouristic organisation (eg social security) are barely satisfying their own primary needs. They have security and safety only as long as there is sufficient workload to satisfy their job being retained. It is in their own interests to ensure their clients do not progress.
As a matter of image, the organisations realise that, to survive, they need token “true professionals.” These are highly trained and dedicated workers who practice in a morally acceptable way. Their existence is cited to maintain the integrity of an otherwise morally questionable organisation. They are also assigned impossibly unrealistic case loads. This is not made public. At Royal Brisbane Hospital (RBH), for example, a case worker for the psychiatrically ill is unrealistically expected to deal with up to 30 or even 40 cases. Of course, management have warned him that to make this public would be a breach of privacy laws, and a legal injustice to all the psychiatrically ill patients.
Government’s regularly tout their intention to completely overhaul their systems. Invariably, this is simply an expensive reshuffle of the organisational structure, renaming of various positions within that structure, and “job-swapping” within the organisation. The ethics and practices employed do not change, nor do the staff within the organisation.
If realistic and meaningful change is to occur, organisational behaviour needs to adjust drastically. Staffs need to be trained in modern humanistic approaches, or modern behaviouristic approaches. Different roles need to be assigned to staff, and different attitudes, so they are not in fear of losing their jobs. Real professionals need to be brought in from the private sector to achieve this, and they need to b allowed to do it properly. Everyone has had a gutful of the band aid “pretend” fixes employed in he past. The high-level, so-called experts within these behaviouristic organisations are simply the people who can identify their numerous past mistakes. They are a product of their own flawed system. They need to be replaced by real experts, who can honestly relate their past successes.
OK. I’ve just realised I don’t have an ending for this. I don’t have a “final solution.” I suppose for one person, or even a group of people, to purport to be able to come up with a solution is arrogant, to say the least. Many have tried in the past, in pitiful efforts to immortalise themselves in history as some sort of lone crusader and saviour. The self-proclaimed experts. The results have been ordinary, at the very best. These “crusaders” have faded back into obscurity.
It is not about glory. No one will become famous for great achievements in this field. Psychiatric illness and homelessness are not politically sexy. They will never be wiped out. There will always be an upper and lower end of the scale. This applies for both mental state, and housing standards.
The attitude has been to identify these people as “out of their minds.” We don’t understand them, so we put them “out of sight.”
We can, as a society, raise the standard. Extreme poverty, and absolute homelessness, can be negated. Maybe this is a job for the economists to ponder. Maybe it is more complex than anyone realises. Maybe it is frighteningly simple. The standard of life of the psychiatrically ill can also be raised, by fulfilling their motivational needs. This is a job for everyone to achieve.