Despite High Rates of Self-Harm, Many Who are Homeless Struggle to Access Care

In April, Philip Menton needed help.

He went to a doctor at Merchants Quay Ireland, near the river, and asked to be referred to the Mental Health Team for Homeless People, in Dublin Region Homeless Executive’s (DRHE’s) offices at Parkgate Street.

He was told, he says, that he hadn’t “a snowball’s chance in hell” of seeing someone.

It’s a mild, misty Friday in November. Menton is sat on a park bench near St Patrick’s Cathedral. The skies behind the rusty-bricked Iveagh Trust building and Patrick Street are turning purple. It’s 4pm. Dusk is close.

As he talks about his experiences trying to get mental-health care while homeless, an elderly man with a walking frame approaches, and asks for help to zip up his jacket.

“I’ll fall over,” the man says, as he grips his walking aid. Menton zips up his jacket. The man moves on.

Menton has been homeless for three years. He has been diagnosed with a personality disorder and PTSD, he says. For 30 years, he has self-harmed.

More than a third of people who are homeless have self-harmed, research by the Partnership for Health Equity in 2013 found. Three-fifths of those asked had had suicidal thoughts. More than one-third had attempted suicide. More than half reported being diagnosed with depression.

But mental-health services for them are understaffed, under-resourced, and under severe strain, say campaigners and people who are homeless.

Being seen by a doctor can depend on diagnoses, too. That, say some campaigners, is a big problem.

Ending Up in A&E

Earlier this month in an Oireachtas debate, Sinn Féin TD Pat Buckley said the Homeless Mental Health Team at Parkgate Street are no longer taking referrals. The reason? Staff shortages, he said.

Independent TD Finian McGrath said the psychologist there is on maternity leave until March with no maternity cover, so demand would only grow.

A spokesperson for the DRHE said questions about this should go to the Health Services Executive (HSE) says. The HSE has not yet responded to queries.

And Menton says staff at Merchant’s Quay told him if he wasn’t schizophrenic or manic, he wouldn’t be dealt with by the mental-health team at Parkgate Street.

But the doctor did refer him on, and he got an appointment the next month. However, when he got there, he didn’t get the help he felt he needed.

Menton says he told mental-health staff at Parkgate Street that he has self-harmed more than usual. “With being homeless and that,” he says.

He says he told them he needed specialist care, but was told they don’t do inpatient treatment, and would get back to him. “Nothing came back.”

A month later, Menton says he had a “bad episode”. He went to the emergency department of the Mater Hospital for help.

Homeless people are 30 times more likely to self-harm than those in fixed accommodation, a Health Research Board analysis of five years of data found.

They are also more likely to use emergency departments. But 41 percent of those that do go to emergency departments, leave before being seen.

A&E is totally unsuitable for people who are homeless and need immediate care because of failing mental health, says Ray Burke, communications and campaigns officer for the coalition Mental Health Reform.

Waiting times can drag on seven or eight hours. People who are homeless often “need to be in their hostel by 11pm or even earlier than that”, Burke says. To eat, they may also need to be somewhere by a set time.

Some homeless people have problems with substance abuse, but A&E units may refuse treatment if a person is intoxicated, Burke says. Addiction can be a result of self-medicating for mental-health issues, he says.

When addiction issues and mental-health issues come together, it’s known as a “dual diagnosis”. Services need to be set up to deal with that, he says.

A spokesperson for the HSE said it is working on a plan for that with the College of Psychiatrists of Ireland. They hope to increase awareness and bring in clear procedures for treating, rather than refusing, those with a dual diagnosis.

Refusing treatment isn’t the only problem with emergency departments, says Menton.

When he was ill in June, and sought help from the emergency department at the Mater Hospital, staff told a security guard to look after him until a doctor was free.

Usually, it’s a nurse, says Menton. But the hospital was busy. “I said I wanted to talk to the doctor. He wouldn’t let me leave for my own safety,” says Menton. But he “kept pushing off me and saying, ‘You’re not going.’”

When the doctor came, Menton told him the problem he had with the security guard. The doctor explained that the hospital had recently hired a new security firm and they were having issues of late with them.

“He just stood beside me saying, ‘You’re not going anywhere. You’re not going anywhere.’ And I was covered in my own blood,” says Menton.

He puts it down to security guards being trained to deal with trouble from the likes of shoplifters, and when he was told to keep an eye on him, he used the same tactic with Menton that he would with someone causing trouble.

Usually, Menton says, there would be a “safety”, a nurse that would be there when you enter A&E with suicidal ideation or are a threat to yourself, to talk to you and keep an eye on you.

Menton asked the doctor if he could leave if he refused treatment, as he was so agitated after his experience with the security guard. The doctor advised him not to, but he left anyway.

Says Dr Austin O’Carroll, a doctor who works frequently with homeless people and other marginalized communities: “One of the best things for mental health is actually having someone who is interested in you and who will listen to you and support you.”

Training somebody “to realise that this person’s depression is not something that needs medication, they just need you to be there for them” would be a big step in the right direction, he says.

Programmes like this do exist. The Simon Community runs the Sure Steps programme, which offers counselling and psychotherapy for those who are homeless. It also provides a day service and out-of-hours crisis service for those who are at risk of self-harm or suicide, a spokesperson there said.

The HSE Press Office hasn’t responded yet to queries about procedures that should be in place when no “safeties” are available.

Going Where They’re Needed

There are other challenges in reaching people who are homeless with mental-health services. Keeping appointments can be tough for many who are homeless, says O’Carroll, who works with Safetynet, a charity that delivers health careto marginalized people.

“They don’t have the structure for it in their lives,” he said.

When Safetynet rolled out a new drug for Hepatitis B, 23 of 40 clients O’Carroll referred for the treatment didn’t turn up for their first appointment. Only two made it to the second appointment.

They changed tack and brought the hospital doctor to their clinic. “We run all the appointments from there. We’ve got all those people on treatment,” he says.

Outreach could be a solution for providing real mental-health services that meet the needs of those who are homeless, says O’Carroll.

Burke, of Mental Health Reform, says people who are homeless are making “very strong calls” for 24/7 access to mental-health services, and dual-diagnosis services.

Two days after he left, Menton returned to the Mater. He spoke to a specialist about his self-harming, he says. “She was really trying to help me.”

But, he says, her colleague went on extended leave. “I had no help then. She said unless you’re in the hospital, injured she couldn’t help me. She said she was very, very sorry but she had to deal with other patients, who had other issues.”

O’Carroll says he has seen this problem before. Being diagnosed with a borderline personality disorder can mean psychiatrists “consider them not their people”, he says.

He doesn’t like that term. “If you actually look at the reason these behaviours exist, [they] result from a childhood trauma. Now usually childhood traumas are related to poverty.”

As people get older, they are labelled with a personality disorder. “Which implies that it’s their fault,” he says. “I’d prefer to refer to it as the social-inequity disorder.”

Menton is still waiting to see a psychologist, he says. He has counted the weeks since he last self-harmed. Twenty-two so far.