Conclusions And Recommendations

Several solutions have been proposed to solve the problem of the high rate of mentally ill people among the homeless population.

Some solutions address the problem of the organization of mental health facilities and aim to prevent mentally ill patients from ending up in the street. Homelessness is the result not of deinstitutionalization as such but rather of the way it has been implemented. Homelessness among mentally ill patients is proof of a shortage of relevant resources and of obstacles to obtaining access to facilities for the mentally ill. Therefore, the commitment to the deinstitutionalization policy should be confirmed, but increased efforts should be made to support the completion of a public mental health care system accessible, coordinated and complete, and emphasis should be put on housing and income support.

Several authors have been pondering the part to be played by the hospital in the treatment of homeless mentally ill patients. Although none of them advocate going back to institutionalization, several admit the need for hospitalization in certain cases and hope that accessibility to this type of service can be facilitated. In an experimental project, Bennet et al. [42], for example, have analyzed the potential value of short-term hospitalization in the treatment of this population. The programme, designed for vagrant mental patients, aimed to improve access to short-term treatment in a hospital. The authors conclude that this type of treatment is underused, whereas it would be beneficial for a large number of the homeless mentally ill.

Christ and Hayden [43] consider psychiatric hospitalization as an opportunity to identify patients who could benefit from the help of social services to prevent them from entering a persistent cycle of vagrancy. People at high risk of becoming homeless should be identified as soon as they are admitted to the hospital and referred to social workers.

The traditional care system can and must be improved, and most authorities also agree on the need for services to be reserved for the vagrant mentally ill. Great efforts have been made to find innovative solutions adapted to the seriously and chronically ill mental patients who become homeless. The following characteristics of the homeless may affect the services and treatments to be offered to this population: their distrust of authority and of mental health care services, their marginal way of life, and their multiple needs.

Thus, commitment will be an important part of the services provided and will often constitute the first stage of the intervention. At this stage the importance must be stressed of winning the trust of the homeless, of first fulfilling their essential needs and the needs they express, the need for flexible, non-stigmatizing and easily accessible services, and the importance of reaching those people in their natural environment and of developing stable social supports. Several programmes aiming at enforcing commitment are described in the specialized literature. Often called "outreach programmes", they aim to reach the vagrant mentally ill patients most resistant to treatment and to improve their access to the health care system. In this type of programme, the vagrant mental patients are reached where they are, whether in the street or in public places, vacant plots or shelters.

Another element important to consider in the offer of services, is to ensure access to cheap or supervised housing. For Shore and Cohen [44], housing should be considered a primary component of the services, which should include diversified levels of supervision and support to fit the particular disabilities of each patient. According to these authors, the need to house homeless people is forcing psychiatry to play a part in the development of supervised model lodgings to keep the most seriously ill mental patients in the community.

Some authors have insisted on the importance of taking into account, in programming the services, the survival strategies and skills developed by homeless people in the street. Important skills are indeed required to survive in such an environment. The punctuality regarding admission times to the shelters, or meal times in soup kitchens, for example, requires a cyclical sense of time, and therefore great adaptability. Homeless mental patients have a remarkable capacity for adaptation and coping. The fact that they succeed in satisfying their basic needs suggests some degree of self-control and of skill regarding the requirements of street environment and shelters. Efforts towards rehabilitation must use this adaptation potential, take into account the strengths and weaknesses of vagrant mental patients and provide them with services designed from the skilfulness and creativity of their survival strategies. For example, their independence can possibly lead them towards a kind of rehabilitation. In short, we must offer them the opportunity to use the resources they have developed, but in a more secure environment.

The "empowerment" approach, a philosophy and a social readaptation technique, has been adopted by several authors. In this approach, patients are encouraged to participate fully in identifying their needs, in deciding their goals, and in establishing the terms of the help programme. Thus, their implication contributes to the self-determination and autonomy of the patients.

Other types of treatment are also proposed. Murray and Baier [45], for example, report on an approach of the therapeutic environment type, which has been tried in a transition home for homeless people with mental disorders. Another example, reported by Caton et al. [36], describes day-care treatment in a shelter.

To meet the numerous needs of this population, several authors note the importance of a complete range of services, which should include a mobile team on the streets (outreach) and an appropriate number of supervised communal lodgings. It should also include access to medical care, to psychiatric and rehabilitation services, to emergency services for mentally ill patients (whether they are homeless or not), to case management services, to general social services and to long-term hospitalization services, when necessary.

Other authors have stressed the need to coordinate services for the homeless, and that this coordination should integrate also the services offered to the whole population. According to Talbott and Lamb [46], everybody's responsibilities must be well established and financial resources appropriate. Some support the idea that services should be integrated into shelter programmes and that a specialized and variously trained staff should provide them on the spot and send some patients to services they know to be accessible. Finally, some programmes have recently been designed to answer the more specific needs of vagrant patients with a double disorder.

These recommendations concern essentially the health system and eventually the social system; however, many authors advocate interventions directed towards prevention: prevention of substance-related disorders among the mentally ill, integration of the diverse agencies involved in housing and social benefit as well as health. But the ultimate goal is to prevent the childhood disorders that render people vulnerable to homelessness, and to develop interventions for children living in social difficulties in order to avoid replication of parents' situations in children.

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