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1. Mental Illness

Homelessness Information Kit for Volunteers

 

Important note

The following is some basic information about mental health, mental illness and the public mental health system in NSW. It should not be treated as medical advice or information about treating a person with a mental illness or disorder. Always seek professional advice if you are concerned about someone you believe may have a mental illness or disorder.

Suicide and Suicide Prevention

All threats of self harm or suicide need to be taken seriously. In most instances of completed suicide people have indicated their intention beforehand. Always actively encourage a suicidal person to seek professional help. Stay with them or ensure someone that they trust stays with them until professional help can be found. If you believe someone is at immediate risk contact a mental health professional for advice or ensure the person is taken to a hospital or an appropriate mental health facility as soon as possible.

If you are working or volunteering with a service that has contact with people who are significantly disadvantaged or are known to have mental health problems it may be important for you to do a suicide prevention course. A number of agencies offer such courses and some are noted in the web links at the end of this section.

Mental Health Legislation – Care and Treatment of People with Mental Illness

In NSW, the key legislation that relates to the care and treatment of people with a mental illness is the Mental Health Act (1990).

Mental Health Act (1990)

The Mental Health Act (1990) provides the following definition of a mentally ill person:

(1) A person is a mentally ill person if the person is suffering from mental illness and, owing to that illness, there are reasonable grounds for believing that care, treatment or control of the person is necessary:

(a) for the person’s own protection from serious harm, or

(b) for the protection of others from serious harm.

(2) In considering whether a person is a mentally ill person, the continuing condition of the person, including any likely deterioration in the person’s condition and the likely effects of any such deterioration, are to be taken into account.

The Act also provides a definition of a mentally disordered person:

A person (whether or not the person is suffering from mental illness) is a mentally disordered person if the person’s behaviour for the time being is so irrational as to justify a conclusion on reasonable grounds that temporary care, treatment or control of the person is necessary:

(a) for the person’s own protection from serious physical harm, or

(b) for the protection of others from serious physical harm.

A mentally ill or mentally disordered person may be, if so assessed by an accredited practitioner, detained in a psychiatric unit involuntarily for a defined period of time. Further detention may be made by a Magistrate or the NSW Mental Health Review Tribunal.

People may also be admitted to a psychiatric unit as a voluntary patient.

Involuntary treatment in the community

The NSW Mental Health Act also allows for involuntary treatment in the community. Community Treatment Orders (CTOs) can be made by the appropriate authority following an admission to hospital. CTOs can be made for 6 months or less and treating agencies may seek a further order, prior to the expiration of a current CTO. They usually specify the name of the treating agency, the type of treatment and the frequency of treatments. Failure to comply with the CTO can mean a person is ‘breached’ and may be re-admitted to an appropriate hospital.

People may also be provided with community mental heath care voluntarily.

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Mental Illnesses and Disorders

The diagnosis of psychiatric conditions is usually the domain of psychiatrists, although GPs may also have involvement in the identification, care and treatment of mental illnesses. Never attempt to diagnose yourself or anyone else. The following information is a general information guide about some mental health conditions. It is not information for use by people who are not professionally trained in mental health.

DSM

Psychiatrists use a diagnostic manual, called the ‘Diagnostic and Statistical Manual’. It is currently in its 4th edition and is known as DSM IV. The DSM IV contains a significant number of conditions and disorders. Only four main types are outlined below: Psychoses; Affective disorders; Personality disorders and; Post Traumatic Stress Disorder. It is recommended that you visit some of the web links at the end of this section if you want more comprehensive information about these conditions.

Unfortunately the incidence of mental illness and mental disorder is quite high in people who experience homelessness. This occurs for a number of complex reasons, including ‘disconnection’ from family and other supports as well as inability to work and have adequate income whilst someone may be in the acute phase of a condition.

Sadly, some conditions (such as schizophrenia) often first strike when someone is a young adult. This is usually a time when most people are able to complete their education and acquire key job skills. Being effected by a mental illness at this stage in life can have an enduring impact on someone’s capacity to work and function.

This does not have to be the case, however. With early intervention or with extra help once someone has received appropriate support and treatment many people can, and do, get their lives back together and function very well in the community.

Psychoses (eg. Schizophrenia)

A number of conditions may be marked by ‘psychosis’. The most well known one is ‘schizophrenia’. People might also experience ‘drug induced psychosis’. A diagnosis of ‘schizoaffective’ disorder is given when someone has a mood disorder as well as schizophrenia.

Psychosis

Psychosis is generally marked by hallucinations and/or delusions (thought disorder), behavioural disturbances and/or psychomotor disturbances. Some people may have one, some or all of these symptoms.

Some people may hear voices or see things that others can’t. They may be agitated and they may think things about other people that aren’t true. They may not be in touch with reality. As you can imagine, a person experiencing psychosis can be quite disturbed by these symptoms and understandably very worried or distressed.

Schizophrenia is very complex and little is known about how and why some people get it. It is now believed that there may be a genetic predisposition in some instances.

Medications

The availability of anti-psychotic drugs can help many people with schizophrenia. Sometimes some people may not be as well helped by these drugs. Some people report feeling very lethargic or restless and troubled by other side effects and may not want to continue taking such drugs. Others may not want to continue taking anti-psychotic drugs because they don’t believe they have a psychosis. Believing our own sense of reality and our thoughts and perceptions is common to all human beings and so it is understandable that some people may have no insight into the fact that their thinking and perceptions do not accurately reflect reality.

Affective conditions (eg. Bipolar or Depressions)

Depression

Affective disorders are marked by changes in mood. Depression can be mild, moderate or severe and is generally marked by sadness, tiredness, lack of interest in life, feelings of guilt, lack of appetite and, sometimes, suicidal thinking. Psychiatrists now believe that there are ‘depressions’ rather than just one type of depression. Sometimes some people with a severe depression can also experience psychosis (psychotic depression). Modern medications (anti-depressants) can help many people.

Bipolar

Bipolar disorder is indicated by episodes of both depression and ‘mania’ Mania is generally marked by a heightened mood, decreased need for sleep, accelerated thinking, grandiosity, excessive spending or doing other pleasurable activities excessively. Mania may also be so severe that it is ‘psychotic’. Mood stabilisers (such as lithium) may be prescribed by appropriate medical practitioners.

Personality disorders

Psychiatrists may also diagnose someone with a ‘personality disorder’. There are a number of these outlined in the DSM IV. Personality disorders are not a ‘mental illness’ (as such) but seen as a disorder that is enduring and inflexible. They effect people’s thinking and functioning and can cause significant distress and impairment. Generally, personality disorders are not helped by psychiatric medications, however some symptoms at some times might be helped by some medications (eg. Anti-depressants, anti-anxiety drugs etc).

It is believed that some personality disorders (eg. Borderline personality disorder) may be related to a background of trauma and abuse. In fact, some of the behaviours that mark this disorder may be closely related to ‘post traumatic stress disorder’. Some people may be so distressed at times that they ‘self harm’ or think about suicide.

As a general rule, psychiatrists try to avoid hospitalising people with personality disorders alone. This is mainly because these disorders are usually not assisted by psychotropic medications. However, some people who are given this diagnosis may also experience a psychosis or a depression at times and may be hospitalised for these reasons. They may also be hospitalised if they are assessed as being a risk of harm to themselves or to others.

Behavioural problems

Some people with either Borderline or Anti-Social Personality Disorder can behave in disturbing and troubling ways. They may become very angry, unpredictable or impulsive. Whilst this can be difficult for the people around them, we must always remember that living with these difficulties can be very distressing for the person.

Sometimes people may be assisted by psychotherapy or cognitive behavioural therapy. Some people who may be diagnosed with a personality disorder may also abuse alcohol or other drugs. It seems to be a common belief that people with these disorders do not recover. However, some people can and do improve their functioning and behaviour with appropriate treatment and support.

Post traumatic stress disorder (PTSD)

There is some evidence to suggest that some people who experience chronic homelessness suffer from PTSD. Some studies have indicated a very high percentage of homeless people have experienced at least one traumatic event in their lives (often more than one). PTSD can be a delayed response to a particularly catastrophic and traumatic event.

PTSD can be marked by:

  • Emotional numbness
  • Intrusive memories (‘flashbacks’)
  • Inability to experience pleasure
  • Insomnia
  • Easily startled
  • Anxiety and withdrawal.

It is important that people with PTSD get help from a qualified and appropriate professional.

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Mental Health Services

Psychiatric care became significantly more sophisticated from the late 1950s and early 1960s. People who had previously only had the option of being contained and cared for, were given newly available medications. With these new treatments, it meant that many people became more capable of functioning independently or with minimal support within the community. By the 1970s and 1980s people were being discharged or not even admitted to the large psychiatric institutions.

De-institutionalisation

Government policy caught up with psychiatric practice and as a result, over the past 30 years or so, there has been a trend towards reducing the number of ‘stand alone’ psychiatric facilities and the introduction of co-located acute mental health units at regular general hospitals. The emphasis has been placed on brief admissions to acute units (if the person cannot be treated by community health teams). Ideally, discharge is made after the person is stabilised on medication or other treatment. They may then be followed up in the community by community mental health workers.

These developments are known generally as ‘de-institutionalisation’. Acute mental health units sometimes do also perform a role in the ‘containment’ of people who may be so disturbed their behaviour is a threat to themselves or others. This is almost always done in conjunction with some other type of treatment. Some people who may be deemed ‘treatment resistant’ or who have disorders not amenable to medication treatment (eg. Personality disorders) may be admitted briefly and discharged as soon as they have been assessed as not a threat to themselves or others.

There is no doubt that this assessment process is a difficult one for psychiatrists and other mental health professionals. Many workers in homelessness services in the inner city have cited numerous examples of behaviourally and mentally disturbed people not admitted to hospital or admitted only briefly. Sometimes a mental health condition may be complicated by the presence of a drug or alcohol problem or dependency (dual diagnosis).

Mental illness, homelessness, family support and poverty

Mental illness does not have to result in homelessness

It probably goes without saying that the wealthy mentally ill usually don’t experience homelessness. Some psychotic delusions could lead some well off people onto the streets, but generally ‘street life’ is for the poor and disenfranchised mentally ill.

Family and friendship support

Homelessness is also something usually not experienced by mentally ill people who have (or still have) adequate familial or friendship supports. Although the behaviour caused by some mental disorders can eventually lead to some people’s estrangement from family and friends, many mentally ill people experience loving care and vital support from their families throughout their lives.

Mental disorders combined with substance abuse and dependence (dual diagnosis) can be so problematic for people’s families that it can cause significant fracture and disconnection from families and friends. People with a dual diagnosis make up a significant proportion of the chronically homeless population.

Disconnectedness and homelessness

Both mental illnesses and substance abuse and dependence can ‘disconnect’ people from other humans and support networks. Some mental disorders do this because the person is delusional and not in touch with reality, therefore meaningful connections with others are difficult. Another example is depression. Depressed people often don’t have the energy or optimism to work on human relationships and external connections. Because of their mood, they may stay away from social activities and opportunities to engage with others.

Drug or alcohol dependence disconnects people from other people because of its ‘obsessive’ nature. When someone is acting compulsively to obtain and take drugs or alcohol, little thought and energy can be given to human relationships, supporting others and seeking support. The drug becomes the number one priority.

It is often this disconnectedness and lack of attachment to support networks and to particular people and places that may become a precursor to homelessness.

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Dual diagnosis

Data collected by HPIC shows that a high proportion of frequent callers (i.e. frequently homeless people) have high rates of ‘self reported’ mental illness and/or drug and alcohol problems. A recent analysis of 78 frequent callers to HPIC showed the following:

Issues/characteristics  % Males (n=53)  % Females (n=25)  % Total
(n =78)
Current/previous drug and/or alcohol problem 87 72 82
Mental illness 47 60 51
Physical disability 51 44 49
Gambling problem 21 0 15
Intellectual disability or acquired brain damage 5 24 13
Other issue/problem 13 28 18

Previous research, such as the study undertaken by Teesson, Buhrich and Hodder in 1998 in inner city Sydney (Down and Out in Sydney) indicated that more than 75% of all homeless respondents had experience some kind of mental disorder within the previous 12 months. Other studies (eg. Robinson 2003; Holmes, 1999; Burke, 1998; Wells and Athanasos, 1999) also suggest a strong link between mental illness, trauma, drug and alcohol problems and homelessness.

The Australian Federation of Homelessness Organisations, in their policy document, ‘Mental Health and Alcohol and Other Drug Issues as Factors in Homelessness’, note that:

Estimates of the proportion of people who are homeless who have serious mental health issues vary, but the level is universally assessed as high. Services for people who are homeless have identified a gradual increase in the participation of people with a psychiatric disability in their services, with estimates ranging from 20 per cent to 50 per cent of the homeless population; and with schizophrenia being a major diagnosis. Some research suggests that up to 47 per cent of those in crisis accommodation and supported residential services or boarding houses have significant mental health issues; while a recent survey found that 75 per cent of people who are homeless have at least one mental disorder, compared with an expected prevalence in the general population of 18 per cent. (AFHO, undated).

Mental Health Supported Accommodation and Housing Services

People with mental illness or disorders can and do live amongst us in the community. Most live independently but some may need to continue to need ongoing support in an appropriate community housing service.

In NSW there are a number of mental health supported housing services. For a complete list see member list of the MHCC or contact the Mental Health Association for details of services.

Links

Mental Health Issues

Suicide and suicide prevention

Mental illnesses and disorders

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Please Note:
While care is taken to ensure accuracy, the City of Sydney cannot guarantee that information expressed here is correct and recommends that users exercise their own skill and care with respect to its use. The City of Sydney makes no warranty or undertaking, whether expressed or implied, nor does it assume any legal liability, whether direct or indirect.