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Dublin's Homelessness and Mental Health Services A qualitative analysis of accessibility, service standards and possible improvements from the perspectives of homeless adults

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Abstract

Homelessness is a growing problem worldwide. Homelessness means more than not having a home to live in; it is characterised by accommodation transience, uncertainty, lack of safety and security, and ‘contrasting spaces of connection and disconnection’ (Robinson 2002, p. 33). There has been a growing attempt at evaluating mental health services available for the homeless population and consequently shedding light on other related services. It has been suggested that the inclusion of the experiences of the homeless themselves are important to carry out such evaluations. This study makes use of the above suggestion and takes a qualitative approach for looking at the attitude of the homeless population of Dublin towards its homeless and mental health services with the help of 7 participants who currently are homeless.
Dublin’s Homelessness and Mental Health Services
A qualitative analysis of accessibility, service standards and possible
improvements from the perspectives of homeless adults
May, 2021
Abhisweta Bhattacharjee
1
CONTENTS
Brief Introduction
2
Background
2-5
Methods
6
Results
6-20
Discussion
21-27
Recommendations
28-29
References
30-31
2
BRIEF INTRODUCTION
This study takes a qualitative approach for looking at the attitude of the homeless population
of Dublin towards its homeless and mental health services with the help of 7 participants who
currently are homeless. Though the focus initially was specifically at the accessibility issues,
post-admission experiences with the service personnel and the kind of care given, and the
possible solutions to improving mental health services for the homeless population from their
own viewpoint, the interview highlighted the roots of the problem and helped me go deeper
than just understanding the attitudes towards mental health services. By the end of the
interview, the cause of such attitudes exist as well as the origin of most problems.
B ACKGROUND
How many?
Homelessness is a growing problem worldwide. Homelessness means more than not having a
home to live in; it is characterised by accommodation transience, uncertainty, lack of safety
and security, and ‘contrasting spaces of connection and disconnection’ (Robinson 2002, p.
33)
Focus Ireland suggests that there were 10,271 people homeless in the week of January 20-26,
2020 across Ireland, including adults and children. The number of homeless families
increased 308% since 2015. Additionally, it was found that more than one in three people in
emergency accommodation is a child. However, this number does not include ‘hidden
homelessness’, referring to people whose homeless condition is not “registered” as they may
be living in squats or ‘sofa surfing’ with friends. Women and children staying in domestic
violence refuges are also not included in these homeless emergency accommodation counts,
with the national figure, strangely, not including people who are sleeping rough (2020,
January 26).
In November 2019, the Housing Department’s official rough sleeping count confirmed 92
people sleeping rough in Dublin, with more in the Night Café. The Department of Housing’s
last official homeless count report of November 2019 week of 18-24 estimated 6696
homeless adults (only) in Ireland with 4509 in Dublin itself and families equally affected.
3
Previously, most people accessing emergency accommodation were single adults with current
reports suggesting an expeditious increase in the number of families becoming homeless in
the last three years. Department of Housing’s estimate states 1,548 families accessing
emergency accommodation in December 2019, which included 3,422 children and 784 young
people (people aged less than 25)
Homelessness, the homeless and mental health problems
Homeless people experience considerable health disadvantages, and are at risk of particular
health problems such as respiratory illnesses, hepatitis B and C, and mental illness (Chung &
Tesoriero 1997) as well as mental health issues.
An analysis of nationally representative data from the 2009 Health Center Patient Survey
explored the prevalence of psychological distress and psychiatric disorders among homeless
youth in the U.S. It highlights the extent and seriousness of mental health problems for these
young people. Homeless patients had worse health status, including a lifetime burden of
chronic conditions, mental health problems, and substance abuse problems - compared with
housed respondents (Lydie A. LebrunHarris et. al., 2012).
A survey in Dublin demonstrated a very high prevalence of mental disorders among homeless
hostel residents, including dual diagnosis was found, which means presence of both mental
health and physical health conditions, which automatically focuses on the need for better
collaboration between mental health services, addiction services/rehab centres and physical
healthcare services. The results also pointed towards the necessity of providing appropriate
mental health training to emergency shelter and hostel staff. An important point upheld by the
study was that research into the mental health status of the homeless should be undertaken
regularly if services are to be planned to meet the needs of this vulnerable group. With a
response rate of 39.2% for the study, 81.6% of residents had a current Axis I diagnosis and
this number increased to 89.5% when current and past diagnoses were combined. Only four
residents had no diagnosis. There was considerable comorbidity between disorders and
between mental illness and substance use problems. When considering lifetime diagnoses,
31.6% had a single diagnosis while 57.9% had two/more diagnoses. However, only 23.7% of
interviewed residents were attending psychiatric or addiction services. A significant number
of residents who did not wish to participate in the study were identified by hostel staff as
having a confirmed psychiatric diagnosis (Prinsloo et. al., 2012).
Mental health services and homeless people
The enormous prevalence of mental health problems among young homeless people
highlights the importance of providing healthcare services which are ‘accessible, acceptable
and appropriate’ (Clark & George 1993). The difficulties involved in providing such a service
are well recognised, and the UK experience shows that ‘[y]oung homeless people appear
particularly unlikely to access healthcare services’ (Centre for Economic and Social Inclusion
4
2005, p. 43). Homeless young people often fail to engage with a mental health service, or
terminate treatment prematurely (French et al. 2003).
A quantitative evaluation of healthcare programmes for homeless people found that a person
who was homeless for longer than one year was less likely to seek regular healthcare
(O’Toole et al. 1999). In the same study, 35.0% of the individuals reported experiencing a
need for medical attention but did not seek it. Comparing individuals whose source of usual
care was ambulatory care sites versus those who used emergency departments, the reasons for
not seeking care rated as “very important” were (1) no transportation (54.9% vs 46.4%), (2)
no identification (51.9% vs 40.0%, p= .01), (3) “don't care what happens” (46.2% vs 20.0%,
p= .01), (4) “can't keep an appointment” (46.2% vs 30.4%), (5) “ask too many questions”
(35.3% vs 8.9%, p= .00), and (6) “can't afford it” (23.5% vs 33.9%). Issues specifically
related to how they expected to be treated or whether they were embarrassed about their
homeless state were not commonly cited.
Health and social services aim to maximise support and access. For example, the National
Quality Standards for Homeless Services in Ireland (NQSF-Standards) aim to ensure person
based effective and safe services, taking care of health well-being and personal development
by making the workforce more responsive and using effective information at disposal
(Department of Housing, Planning and Local Government, April 25th, 2019). However, the
services may not be effective after all (Rosenheck R. et. al., 2002). There have been marked
differences noted in perspectives and priorities between clients and service providers, which
can considerably affect the quality of services or their accessibility (Rosenheck R., Lam J.
Psychiatric Services, 1997).
‘Homelessness and Mental Health: Voices of Experience’, an investigation headed by Dr
Rebecca Murphy, mentions about homeless people being turned away from Dublin hospital
emergency departments for not having an address. “This ineligibility to access mental health
services meant that the service users’ mental health needs were not given attention despite
being a significant factor in their relapses”. The report, produced for the Dublin Simon
Community and Mental Health Reform, also found homeless people experiencing stigma
from staff and other patients in emergency units with inadequate follow-up care once they left
the hospital. The study involved discussions with 10 homeless people who had mental health
difficulties and with five Dublin Simon Community staff who worked with the homeless
population. It was found that there was little understanding of the relationship between
trauma, dual diagnosis and homelessness and that providers were often not appropriately
trained or aware of the specific issues homeless people face. There were also no crisis or
crisis outreach mental health services for homeless people (June, 2017; Rebecca Murphy
et.al.). The study effectively “illustrated the struggle homeless people face in accessing
mental health services including bureaucratic barriers, the double stigma of homelessness and
mental health difficulties, and being denied mental health care due to having a substance
abuse issue", Mental Health Reform Director Dr Shari McDaid said.
5
The Irish Examiner’s article dated 8th May, 2019 published a report by the Merchant’s Quay
Ireland (MQI) in which it said that MQI’s mental health team had worked on 767 crisis
interventions since January 2019 which was a higher rate than for the same period in 2018.
Sarah Scully of the MQI mental health team talked of the increased interventions and that it
was hard to pinpoint in some cases whether mental health was a contributing factor in
someone becoming homeless, or whether homelessness had affected that person's mental
health; "Obviously homelessness itself creates a recurring trauma," she said. "A lot of the
people we are seeing, more and more are coming in with an experience of childhood trauma."
She observed that MQI’s work had a positive impact on many clients, linking them with harm
reduction services and GPs as well as offering therapies such as cognitive behavioural
therapy.
In the Journal.ie article dated 16th June 2017, ‘The Homeless Adults Speak Out on Mental
Health Group’ said that there were two main issues that need addressing:
Inadequate 24/7 access to quality crisis mental health support
Difficulties getting access to mental health services if you have both an
addiction and mental health difficulty.
The Homeless Adults Speak Out on Mental Health Group was involved in the research of the
'Homelessness and Mental Health: Voices of Experience’ report. A staff member mentioned
that gardai or hospital services refuse to take in service users expressing suicidal behaviour
and having an active substance abuse issue due to the Mental Health Act, creating difficulty
for workers trying to provide support. It was found that housing security and regular
counselling aided in helping with the post-traumatic stress of being homeless. Head of
Emergency Services in Dublin Simon Community, Claire McSweeney, said: “Bricks and
mortar alone will not solve the current homeless crisis and it is very clear that once a person
becomes homeless, the deterioration in their physical and mental health can be both rapid and
debilitating. Rapid access to support and specialised care is vital to ensure that people can
address what circumstances brought them to be where they are and provide the emotional
support for them to recover from the detrimental impact of homelessness.”
The project explores the perceptions and experiences of a homeless female who is currently
experiencing homelessness. It aims to describe her engagement with mental healthcare
services and the experiences which either had a positive or a negative impact on her
relationships with healthcare personnel or the system.
It also builds on a growing body of research that demonstrates the value of consulting
homeless and suffering people directly and asking them to describe their perceptions, views
and experiences of the mental health and social issues which affect their lives
6
METHOD
The inclusion criteria for the participants were:
1. Having a current episode of homelessnes at least for 3 months
2. Aged above 18 years
3. Currently in Dublin
4. Having accessed any kind of mental health services/help in Dublin at least once since
the onset of their episode of homelessness.
For the comfort of the participants, they were present at the Dublin Simon Community office
while the interview was conducted via video call, which was audiotaped and transcribed
verbatim.
Interview began with asking the participants about their story of becoming and being
homeless which was sufficient to trigger rich and descriptive responses. They were then
asked if they had had any experiences which they could share of accessing and using mental
health services (or any relevant services) in Dublin. When such experiences were mentioned,
participants were prompted for more detail to appropriately explore the scenario. However,
the interview was majorly participant directed. Thematic Data Analysis was then applied to
analyse the interviews.
RESULTS
Causes of
mental
distress
Beliefs
Accountabili
ty
Mental
health
services
Staff and
services
High rents
Normalizatio
n
Government
Preferences
Accessibility
Stigma
Care
Hotels/other
places of stay
Quality
Initiation
Housing
Community
Outcome
Quality
Rules
Addicts...
Steps taken
Key workers
Assumptions
Stigma
Other
homeless
population...
Government.
..
Services
7
DOMAIN I: Causes of mental distress
High rents:
P1 “But I really started to struggle with the rising rents.”
Stigma:
P1 “I haven't been stigmatized, because I'm homeless by people in the public. I have been by
judges, by family law courts, by social workers…”
P2 “I never went for counseling, I don't know, I just thought it was something to be ashamed
of. Maybe I thought people would look down on me and think I'm silly, or…”
P3 “I think I was trying to figure this, you know, I even went through social stigma for all
this, I can't cope with what I'm having...And it's so sad because it makes me give up hopes
you know?”
Housing:
P1 “So there's really no place for me. But I can see how people will feel hopeless. And like
our hotel, we're separate, but in the more chaotic hostel, it's just non stop drama.”
Rules:
P1 “So you're not allowed to have people into your space.”
P1 “It really affects them that there is no common area where we’re, we're not allowed to
mix. We're not allowed to talk. And they were not allowed to have conversations with each
other in the hallways. We're not allowed to talk to anyone outside of the hostel where
anywhere it can be seen on camera.”
P6 “if you don't have an address then there is certain doctors that will see you but it's how
you get treated, in doctors it's how if they don't like you and you have no other option but you
have to go to that doctor…you're stuck you're stuck because you can't access the other
doctors because you've no address.”
Assumptions:
P1 “People assume that you're on drugs, and that's why you're homeless”
Services:
P3 “I was terrified the first time I was up in there, scared all the time, behind the doors
closed to keep out people and terrified that they're trying (...), you know what the stairs they
didn't clean them and there was vomit on the wall and feces. (...) and just mentally it was
awful.”
8
DOMAIN II: Resources
Links:
P1 “there isn't linked up thinking...so what was expected from me from social workers would
sometimes be contradictory to what the rules of the place was, and they don't, they don't
communicate with each other, no linked up.”
P2 “I went from hostel to hostel and I wasn't linking in with support networks which I should
have been doing”
P6 “There's no wraparound service like...the services don't really link in with each other, the
agencies, so they're not wrapped. so every time you go somewhere you're meeting somebody
different and you know, it's like a lot of people fall through that, fall through the cracks then”
Misuse:
P1 “And, but there's no, if you want a prescription for some legal drugs, we'll get that pretty
easy, and that would be a big problem. I would say that's how a lot of the more vulnerable
people in the homeless get into drugs because they're prescribed mad stuff...They’re
prescribed benzos and these kind of things that can easily turn into a proper serious
addiction, you know what I mean?”
P1 “In Crumlin, some of those houses that were built as part of, like, social housing in the
50s, however there’re millions now and they're owned by private landlords who rent them out
for...so stupid, you know?”
Privatization:
P1 “Because private businesses are in its being; are taking care of a social problem.
Whatever money they make, they have no responsibility towards the residents”
Improper handling:
P1 “Look after addicts, they’re not trained...So they can be very crude to the more vulnerable
people, residents that have more complex needs”
P1 “But, again, about the infantile, infantilizing adults, treating them like children, they start
to act like children...People don't get an opportunity to have self responsibility. You can
become, you can become, what's the word? Institutionalized?
P1 “And you're going to do better if you act like a victim, so we're creating more victims and
victims end up taking drugs more, like, you know?”
P3 “some of them hostels are really really really bad, there's a lot more violence in there, and
I'm afraid of violence you know? I have PTSD. I have been through a whole lot of, you know
I've had a meltdown, yeah, so no drugs, and that was how bad was the situation”
P4 “So I'm walking around trying to get over addiction with no beds available for me, you go
back into (addiction)”
P6 “my mom was from Carlow so I would have spent a lot of time in Carlow and, like there
was a hostel down there and I did ring and ask could I stay there, but they never had any
beds available...so it wasn't an option I came up to Dublin and the same thing I rang the free
phone number under like no, a few times they told me I was from the country I had to go back
9
down to country and go to a hostel down there, but like there was no availability in the
hostels down there.”
P6 “so someone is having to spend six months of their life going at detox and treatment. To
come out with nowhere to live. Like, it starts in a stable environment like if you don't have
that stable environment, how do you continue on your routine and structure, how do you how
do you feel safe you know? I mean, how do you not go back to the substance or whatever
coping mechanism you were using if you don't have the right thing and place for you know,
you're gonna go back and you're gonna use it like. so that's a massive problem at the moment
and that's only started in last few years”
P7 “just yeah sort of there, it scared me, you know?... just didn't feel safe (in the hostels)”
Lack:
P1 “ Literally all the staff do for suicide prevention is check the rooms regularly to make sure
no one's killed themselves, to find the bodies. That's it. There's nothing, there's no; they don't
care if, if a, if someone was showing suicidal tendencies…”
P3 “I've been to hostels where there definitely weren't enough resources”
P3 “The staff are at the top of their throat you know, they can't sit back for any hostel.”
P3 “But whatever she (girl with severe mental illness) was going through, she's gone to a
hostel, she's going around from hostel to hostel (...). That was very sad for me to see and so
that's crazy...I feel like there should be somewhere that just; there’s not enough care for
people who, you know, that that like honestly can't help themselves”
P3 “there's only one hostel in in the county, (name) and the hostel was full anyway. You know,
so that's very sad so he just came back to the county you're from and there's no room in the
hostel. so there are major loopholes the system. And that's how people are falling into the
cracks of homelessness.”
P4 “Because there's only three clinics for methadone. Not a lot of help when it comes to
methadone.”
P4 “I would never be able to afford them like that. I think the people that we know in the
services at the moment, there's good houses there, but it's not enough”
P6 “three or four counties that fall under the one the one area and they only have maybe one
team for that whole like area so it's I think the problem isn't recognized enough maybe and
there's not enough like that the money the funding is not being put into it.”
P6 “I think it's (number of detox beds) 60 something for the whole country. Like for the
amount of people, the numbers do not work. we could use 60 just like just for Dublin”
Pandemic:
P1 “It's very hard for the addicts at the moment with the lockdown to get into treatment, the
center.”
P3 “I should have went to the hospital but didn't prefer to go because of COVID, you know,
but the staff were really great, and they arranged virtually to see a doctor, you know and then
I was told to go to the hospital.”
P3 “now he (counselor) has to talk to me over the phone, and I just couldn't do it, it just
wouldn't work, you know like I've never met this person been that i have been talking on the
10
phone. So obviously that wasn't effective. I don't think counseling works on phone, you know,
you have to be able to explain somebody or make somebody talk, so yeah that doesn't work.”
P4 “Last week, 4 of my friends have gone back into addiction and are in hostels at the
moment as I speak to you. Now (during pandemic) people can consume”
P4 “You would sometimes get food from the shops and the shops are closed. It's very little
people, the people that, care about the people on streets. So they struggle. It's threatning
people around. So from their point of view they're having it an awful lot harder”
P7 “I suppose one of the things was the amount of people into places. they you know, they
only let so many people in now [COVID], it was more like, in both of the hostels that I was in,
was four people in each room, you know? four complete strangers you know that way? two
bunk beds in a small room like so and even though I got on well with most you know, it's it's
still a lot of, Still a lot of men in one room, you know that way? Especially if everybody has
mental issues and addiction problems and stuff like that, you know, it can be quite quite hard
to get it all into one room.”
P7 “it was still big, the hostel was still big but there was half as many people in it. yeah so if
so if you needed anything or you wanted to talk to anyone you didn't, like everything wasn't
you know a mission to get done because you know, there was only a few of us there like so
was was actually quite nice I thought you know.”
Exploitation:
P1 “All of those charities have become, um, more cash cows if you ask me.”
P1 “No the resources are going into the people's pockets, that's the problem. The person who
owns the hotel is more than likely to get a million euros from the homeless people.”
P3 “The sad thing about this is like, because my mental health had deteriorated and I feel a
lot of corporations took advantage of that situation”
Staff and services:
P1“The staff are rude there.”
P1 “Three people have died this month. This person's running them up pulling them off the
ceiling, they start off, you're like, Hey, I'm gonna help you. But by the end of it, they just get
worn down.”
P1 “There's a lot of lip service, but there's not really any real supports.”
P1 “Yeah, it's, most of the hospitals will be run on a prison routine.”
P1 “Like, this is an, this is a charity organization. There's, this should, you know what I
mean? The, this is a not for profit. The ones that are government run are for profit. That's
disgraceful.”
P1 “The mental health services in this country are a disgrace.”
P7 “You know dealers swarm into recovery houses.”
Bias:
P1 “Which I think is really interesting because it's just, it's catered towards addicts…”
P1 “You're more likely to get a place if you're an addict.”
P1 “I think this is for people who have addiction problems to support them. For someone like
myself there’d be no advocates.”
11
Transparency:
P1 “There's a lot of corruption; accountancy in Dublin City Council seems very corrupt as
well. It's not, there isn't a, it's not transparent enough. Like, it doesn't really make sense. Who
gets housing, social housing and why?”
P2 “I am number 90 on that I started off six years ago and I was four hundred and something
but I check it every other day and at the moment it doesn't seem to be going down now...I
have been to viewings, I have set up emails and I've got absolutely nothing back. I actually
gave up because it wasn't getting anywhere. when you meet when you go to a viewing
because you have, they basically take your details and I just heard nothing back, you know.
P3 “I don't understand how they make the decisions they make, you know? How do they work
and who do they put on priority because yeah, that was a hard one for me you know. Yes
definitely that was unclear and the system should expand to other house letters you know”
Referrals:
P1 “I was never provided a social worker to find out why I was homeless. They just took my
child away from me.”
P1 “I had a housing support team. And they were like, Looks like you're gonna be homeless.
Like they were useless. They were just... Useless, you know, so.”
DOMAIN III: Beliefs
Normalization:
P1 “And I think that we're nearly in danger of becoming normalized.”
Care:
P1 “But the bigger. the bigger groups don't have any personal responsibility or care.”
P4 “We need a safe environment. If you give a person a shoulder, Addiction and
homelessness don't happen in a safe environment.”
Community...:
P1 “ Oh, people are over educated. People are encouraged to have these disorders, you
know?”
P4 “it's a slow community”
Addicts...:
P1 “And they tend to go after, they tend to have a good way of manipulating the system”
Stigma:
P1“But I think there's less of a stigma actually at home because so many people are
affected.”
P2 “I never went for counseling, I don't know, I just thought it was something to be ashamed
of. Maybe I thought people would look down on me and think I'm silly, or…”
12
P4 “It always destroys people from inside, mentally. Become almost numb and become a cold
person...you turn cold and you don't wanna let anybody in because you feel weakness, if
you're understanding what I'm saying. You don't wanna be vulnerable and ask for help.”
P4 “people see you going to any services you're looked down; he's vulnerable already and
he's lost his heads. You know some people say that and they take advantage of it.”
P4 “everybody would be happy to take the services, but that takes, I don't know how, I just, I
just cannot be broken enough to be expecting help”
Other homeless population…:
P1 “I've met a lot of homeless women, who’re, they're just waiting. And then their minds are
like, oh, I’ll give up the crack when I get my own place. Like I certainly felt that.”
P3 “but most of them (...) and they are not trying to move on. They are satisfied with the way
things are, but that's because you know they're taking drugs to cure what's really gone
wrong...you really have to want the help.”
P6 “like a lot of homelessness, I'm not saying all of it but a lot of that comes from drug
addiction and stuff”
Government…:
P1 “Every year, it's getting worse, the rents getting higher. They're bringing in more low paid
workers from other places. There's less jobs for me and there's less places for me. It's the
government's dream.”
P1 “And I think is interesting that if you bring this up, it’s seen as very far righty or racist,
whereas unlike ‘Hmm well actually, why are governance in cahoots with people who are
smashing up their countries who don't want to be here more than me’, you know what I
mean?”
P1 “They don't care about low paid workers, because they own them.”
P4 “The government, I don't know. Obviously they could do more”
Services:
P1 “No. It's just going to be more bullshit. Another clango. Someone coming in and being
like, okay, yeah, right. That's your counseling.”
P1 “I think that the student accommodations that's been banged up all around in lightning
speed. I have a feeling that a lot of us are going to be moved into those places in say 10 years
time.”
P3 “the only way out of getting house is that, get yourselves priority. Get yourself medical
priority, exceptional grounds, you know, it's really really really hard to get these things. I
should've been given much of these faster because there were situations where I wasn't; I was
asking for help for years, about two or three years before I broke down, had a breakdown”
P3 “I think once you fall into homelessness it takes a long time to get rebuilt, and because
you have reasons for falling into mental health problems”
P3 "For me the only way I can see out is HAP”
P4 “People contact (...), different services for different reasons. (...) some are forced. And I
think forced services are exactly what you don't want. You need to make them accept it”
13
P4 “They're Not being taught there's a way around this (committing petty crimes, going to
prison, coming out, repeating again) . You can get away from that kinda life.”
P6 “I think the whole system is a bit messed up like you know, and in my opinion, I think a lot
of money that is made from keeping people on methadone, keeping people out of them
services as well”
DOMAIN IV: Accountability
Government:
P1 “So nobody's really, it's very disingenuous, like the government says, Oh, we put this
much money for homelessness. Homelessness has become an industry now. There's no
accountability for outcomes.”
P7 “I think the changes have to be with the government that's being honest, yeah if anyone's
to have a chance. Well I was just gonna say with the resources if, you know, if in
homelessness wasn't as bad the resources that they put into the homelessness could quickly be
put into something else like addiction, you know what i mean?”
Hotels/other places of stay:
P1 “He doesn't get a deduction if a homeless person dies that will be filled up the next day. It
means it doesn't matter if we're dead or alive, or what the outcomes are, that nobody cares
about that, we're just stuck.”
DOMAIN V: Mental health services
Preferences:
P1 “I have my own one (counselor) that I pay for privately, but no. Nothing we will expect
from them for years possibly.”
P6 “yeah at the moment at the moment I have a counselor now that I see, but I don't see her
in person at the moment, but I zoom call we have a zoom call every thursday evening and
she's been brilliant you know, and it's been the good thing is it's been the same counsellor as
it had been with the simon, you know that way.”
Quality:
P1 “And the quality of the counselor (exasperated sigh). If they're doing it for homeless
people, a lot of, you know things like, it's not what are they.”
P1 “I remember I've done like, counseling, and, for alcohol a few years ago, because I was
forced to do it. And all you had to do was show up, sign your name and go away there, like
there's no real care or attention. It's lip service.”
P2 “I never woke up at five o'clock in the morning now I'm making my business now to wake
up 5 o'clock every morning, prepare myself yeah well I do that the night before. I attend the
groups it helped me a lot. the counseling definitely helps (unclear) or anyone that has any
fear of counselling, I'll ask them to give it a try, you know. Give it a try and it's really helped
me prepare for me next job”
14
P3 “I really felt like I needed to, in the hospital, get some mental help, and they just fed me
tablets you know? And they just said they can't help me, they just don't have space for
anything like that. The service is for people that are actually suffering from mental health. It
was really really really bad, really bad, you know”
P4 “Mental health is a joke.”
P5 “My experience was good it was really helpful really was because, it is a therapeutic
center. It was a trauma based therapeutic center, so we talked about stuff that happened...it's
bringing out the stuff that happen in the past and it's been about I found it really helpful, you
know, really but myself.
P6 “my doctor referred me to a psychiatrist but I had to wait wait, the waiting list for the
psychiatrist was a few months and then I did go and yeah because it's because it's HSE, Like
so and you have to wait.”
P6 “there's no wrap around services but there's no follow on do you understand? there's
nobody that really checks in a few weeks. it's like they're just kind of tick boxes like the doctor
you go to the doctor with a problem the doctor will send you to psychiatrists, psychiatrists
then will evaluate and see you and they're like, there's nothing we can do like, you know,
because you're not actually you don't need to be signed in somewhere, so it's. so I remember
after last psychiatrist then nothing, nothing, nothing came of it. Nothing. so, you're kind of
just back to square one.”
P6 “They don't know like unless you're actually really mentally ill like they're, they can't help
you with like homeless situations or with, they can put you on medication which they did”
Outcome:
P1 “There's no outcome.”
P2 “I've learned to open up more”
P6 “I think they're just not enough money being put to sorting out that problem to begin with
because for instance even the treatment center that I went to two years ago, they had to be
closed, it was an HSE treatment center and it was for people that were clean like that had
detoxed already and they were putting in a structure and learning how to how to cope with
daily life and give them routined structure and a place where they can do some work on past
issues and stuff like that, so it doesn't come up and you know, (...) so they can deal with that
stuff to move forward and now it's been closed down, you know, it's been closed because and
they want to put the money into stabilization units which is fair enough as well like people on
do need to get stable but their also needs to be a follow on to keep people off of from
reentering into the premises and into that cycle”
Steps taken:
P1 “Like, if they suddenly said no, oh, there's a mental health service you're allowed to go to
(exasperated)...No, there isn’t, I wouldn't have any. No, I have never come across it. I mean,
I’m 40 and I know about homelessness since 17.”
P6 “definitely needs to be more of a priority, the same as mental health needs to be more of a
priority, in country like more money more funding needs to be put into this but it's not.”
15
DOMAIN VI: Improvements
Housing and shelter:
P1 “No. Social housing (laughs). Affordable housing. If you want to get rid of like 99% of all
problems, (unclear) it’s housing.”
P4 “Our leases should be longer. Say minimum, if you want to as a person, two three years
rather than one year, maybe 5 years. At least people will be stable for them five years, do you
know what I mean? Obviously, if you're wrecking the house you can throw me out, but if
you're paying the rent, not for them just to be able to turn around for a profit. If you if you'll
keep that place to a standard, and paying the rent on time, there's still people being thrown
out on the streets because the landlord doesn't want the house, he wants to sell.”
P6 “I think the hostels situation could there were being changed a bit like, so there is like
there's emergency accommodation but [if] their beds are be full, there [should be] long-term
hostels”
P7 “oh definitely, definitely would have helped and Like I had taken drugs in the hostels
which I've never taken before. so to say that the the to have the two (drugs and alcohol) of
them separated would be a lot better because you know, even people that don't have
addictions went into these hostels end up drinking and taking drugs, you know, so yeah
looking for different, I suppose you'd to be looking for different categories of different hostels,
you know, which is which you know, which would be hard…It'll be definitely definitely better
for everyone if there was different different hostels for different things but I can't see it
happening, you know?”
Schemes:
P1 “Like, I'd rather there was a scheme that right if you can pay rent for six months, we're
going to find, we're going to give you a social housing because you've proven that, like, I
would jump on that scheme.”
P4 “Maybe to bring people to go around and have a chat with a person on the street, spend
40 minutes to make sure that they understand that they're human beings. Because when you
live there and you don't think I'll go back, you don't think you're a human being. Positive
things you have to do to support. So you get the basic things running.”
P4 “The first step for the person is take away drugs, and give them a stable base to work on,
rather than to come out of prison, nowhere to go, out on the streets, and the services cycle all
over again, back to your clinic, back to your crime, back to prison, back here on the streets
with nowhere to go. It's like a vicious circle”
P6 “if there was something to support mothers that are in addiction with their children, of
course that would make a big difference. they wouldn't feel afraid to go and ask for help and
then when they do go and ask for help it's actually available, you know? yeah because it's like
you said about breaking the cycle like, you know”
Social codes:
P1 “But it should never have been allowed for people to be allowed to own the social
houses.”
16
P4 “would help you more to give them a safe environment if they are coming out of prison.
Work on that person, get them out the streets and that vicious circle will break as soon as you
do that”
Decentralization:
P1 “We have a lot of places where you can stick houses, everything is in Dublin, you know
what I mean? It’s stupid. We need decentralization.”
P6 “I think each county in the country should have their own emergency services. and then
maybe that might take a bit of pressure off people coming to Dublin and You know...but they
had no other option when there's nothing down the country and people are looking for help“
Staff and services:
P2 “And actually I think there should be more services available to help people because I
think these services are great. I think there should be more services out there opening up and
let people go in and actually see, even if for the first time, you know? Lot of people go into
detox for the first time or a counselor for the first time, I'd advise anyone not to close the
door, you know? There should be more services available to people to give their life a second
chance”
P2 “I think they are lacking, there's a shortage of single accommodation. there's a lot of
family accomodation which is great. but I think you could do more of a single individual's
place for homelessness, absolutely”
P2 “counseling services mental health, you know, mental health is a big issue in here. there's
people going doing suicides all night long but mental health need more services, you need
more support for these young people old people it doesn't matter you know, there's a lot of
people committing suicide. So you just can't hang in you know, the mental health of this
country is gone or it's on the raise for people, you know, they just need more services to
access for these people they're gonna get the right help and allow them to live their life
because without that, it's just gonna get worse.”
P3 “but I try to look if they have any information that is easy for them to hand on, the
charities that help the housing, they have to really stretch out”
P4 “(We need) To see what's stopping people from going into services.”
P6 “There should be something for people it should be maybe a separate list that people can
register as homeless, choose to access the recovery support after a treatment not necessarily
looking for houses, they just want to be able to access the, because Peter McVerrys, all of
their houses, any of, like the Simon, if if you're not registered as homeless in Dublin, they're
homeless recovery houses, so if you're not registered, you can't access them. It is a huge
problem.”
P6 “if you ask any of the services like any of the recovery services, the biggest barrier, I think
is people if you're not registered as homeless, you can't access their their aftercare support
housing so like maybe if they want people to go back down to country and register as
homeless, there needs to be recovery houses down there that that are accessible to people that
have done treatments, you know?”
17
DOMAIN VII: Staff and Services
Accessibility
P2 “I had no medical card, so how do you use services?”
P3 “things are crazy you have to find people for yourself you know, they're tired of helping.
You know it would be nice if you get a hostel (...), somebody who came up and told you about
these places. We find out about these places from other homeless people. Places that might be
better...You may be homeless for more than 3 years before they can help you”
P3 “so if you're not from Dublin, if you're from Kildare, Wexford, and you're in Dublin, they
don't put you up in a hostel, they tell you to go back to where you're from, and so most of the
people sleeping in the tents are not originally from Dublin...So some of them are genuinely
afraid of coming into the hostels because they're afraid of other people”
P4 “And then other services, I can't make sense because they aren't available.”
P4 “Did I try harder to find out about them [the services available]? no. Well. Nobody also
came over to explain. So that's saddening”
P4 “A person from the services to go around and approach them, here's our link, I don't
know. there's lack of information in the community that need the services”
P4 “I'd prefer crying and get comfort, because then you have to go into a Garda station and
they have to be your lawful guardian. [when asked about accessing counseling services]”
P4 “But bringing yourself there, just not accessible”
P5 “No it was easy for me because I was in town. I was just living in town but I don't know. I
don't know. I just I just knew where to go. I just knew where to go because I was already
going to the Anna Liffey which is a drug project and they told me about the lantern they told
me about where it is, so I went up to the main office and I was talking to the staff. And they
told me what I had to do to get into Lantern. I know it can be difficult for some people and it
could be difficult for me as well, but I think I was just lucky they (connections) worked out
good”
P6 “...but like if you're ringing like an emergency accommodation and they don't have,
they're full so there's like, it's actually really hard to find somewhere to sleep like yeah the
accessibility is really [low]”
P6 “you hear it all time that like homeless services don't discriminate kind of towards people
from the country, but they actually do like in Dublin it's it's hard they will send you back
down. I suppose they have enough of the problem in Dublin so they want to try and sort out
the people in Dublin and they want you to go back down to country, but like Dublin is bigger
and has more services, you know, so. It's really lacking I think down the country you know,
and even for, even for follow-on like there's eight houses here and they hold two people each
the 16 people that are secured accommodation for two years, like that's only 16 people.”
P6 “I think the waiting lists for people that are looking for help even for people to get into,
when I was trying to get into detox I was, it was like it was nearly a year trying to get in. A
really long waiting list and, you know, some people kind of give up hope or they lose
motivation and they're like, you know or anything can happen in that length of time when
people are living like that every day”
18
P6 “for me to access services like methadone clinic and stuff like that, I had to travel to
Dublin [from Carlow] and there there's only two buses a day like you know, so and then
there's also somebody might not have money to travel”
P6 “that's the only difference that I would have noticed a lot is the gender inequality, the
gender imbalance, but it's because of the, it's because of, like sometimes women don't have
support. like if they have kids under addiction who want to mind their kids, they don't want to
put their kids into care, you know, so it's like they're a lot more stuck.”
P6 “there's one treatment center in Dublin that would take children with their mothers. That's
it...I don't even know if there's another one and I don't think there's anymore in the country all
right one treatment center that will take mothers, and their kids have to be under a certain
age as well. I think to take them up into four or five. I'm not exactly sure but, so that helps,
you know, but like one treatment center, you know”
P6 “I like that Dublin has all of, the majority like you know, if you were to actually look into
what the little towns and the counties in Ireland have some of them have nothing. some of
them have no resources whatsoever, they'd have to travel a long way to get you know to first
some sort of service. but then your tied like yeah in Dublin yeah, they have a lot of resources
but, If you're not registered as homeless in Dublin, you can't actually continue on with the
resources. so it's very it's it's messy”
P6 “I wasn't in care, you know from people are put into foster care they have, they have a
home they have somewhere to be but when you're 16 and you're not an adult you're kind of
your in that age gap where it's like, where do you even go for help like how do you, you know,
and that's like I don't even think there's any, or I wasn't aware of it if there was because I was
down the country at that time I'm not sure if there is in Dublin but I don't even know if there's
any hope there's any hostels for teenagers, you know.”
Initiation
P2 “I didn't know what they expected, didn't know where I was. I knew it was a hostel, but I
didn't know what they expect when I was going there. it's a bit traumatic. I think honestly, it
was a bit mental, you know, and I was scared obviously, you know, it was the first time ever.”
P2 “When at first I was homeless, I was called around a bit, and you know, I had no access to
key workers there no kind of help...I didn't have that support network at the start. There was a
kind of a meltdown”
P4 “these services were simply going to experiment you; two talks twice a year. Making
people aware becomes hard.”
P6 “what's another problem now that I'm thinking of it, people from the country that come up
from the country and do treatment in Dublin, unless they are registered as homeless in
Dublin, they can't access the recovery supports the aftercare housing. so only that I am
registered as homeless in Dublin since 2016, I could get a whole, I could get (...) after care,
recovery housing in Dublin where I've done my treatment I've done my detox and all my
support my counseling all my supports are here, but if I'm not registered as homeless here, I
can't live here in these services. So I know loads of girls that had to go back down to country
after doing detox and treatment in Dublin and having their counseling, having their supports
in Dublin. Why they came from the country in the first place because of the supports in
Dublin and now they're a lot more stricter about accepting people under homelessness
19
because the numbers are so high so they have to go back down to country after doing all
this.”
P6 “it's a treatment center in Cork and they have their own house but like you have to have
went through their treatment center to access their health recovery houses, there are no
recovery houses and if they are they're attached to a certain Center, you know, yeah, you're
pretty much going back down to nothing, to just where you started.”
P6 “no it's really hard [to register as a homeless]”
P6 “I know I know a lot of girls since then to have tried and fellas to have tried to register
and they won't accept them. they tell them to go back down the country and register as
homeless down there. That is a big problem right now.”
Quality
P2“in the hostels, it was bad, you know; it would effect your mental health, physically
emotionally, mentally especially you know”
P2 “you get scared, you know? There's a lot of bullying going on; it is tough”
P3 “They (some services) were so cold. I'm now kinda used to it (laughs), but it's all those
things being setbacks”
P3 “I know she was placed (...) in what was the worst hostel which was called (name) and
there's a lot of drug abuse and prostitution and this girl was 22, never been on drugs, she was
so quiet (...), she knew she could be a victim she was so afraid you know? But she's housed
now, she got through HAP.”
P3 “She was so shocked, the staff were all rude, the residents there were all getting drugs
into the building.”
P3 “I don't know whether there's difference in standards or are there qualifications here that
hostels, others don't look for. I don't know if there is (...) because the standard here of the staff
is high, but at other places it was very low. There are more cleaner here and the
qualifications here are better, like they are from the social field, basically social worker, and
the basic stuff, they're really doing it (...). You know some staff may not have the
qualifications necessary to work here.”
P3 “just so amazing the quality of the service that they're giving out there: food, clothes,
tents, things like you know, anything you need, and these people because they have saved so
many people sleeping rough, so much of hardwork and homelessness, they're really getting
the resources now...”
P4 “The hostels are a joke (laughs). I would be in the streets than to be in them. You have to
carry weapons, just to protect yourself at that place, put your head down and like (...), It's
safer on the streets. I mean I was shocked. Them hostels, should be, closed. Let someone from
the services go and spend a week themselves. They'll never go it's that bad there yeah.
They're not safe for anybody”
P4 “Genuinely not safe place, those hostels. Streets are safer because there, there's cameras,
CCTV”
P4 “Did not feel supported in most parts of the journey”
P5 “I would never have got clean in the traveller accommodation because there's so much
drinking there's so much drugs but I wanted to get away, and I found it difficult to get a place,
to rent an apartment, especially with no job”
20
P5 “Anna Liffey was very helpful yeah they did help me, but all we're doing really was just
group therapy and talking and I know but it's helped, you know?”
P5 “Well in the day program it's not, if you if you give a dirty urine, nothing's gonna happen
apart from maybe they might warn you or they might talk to you or whatever, see what's
wrong but nothing really happens, so like it can be it's kind of relaxed a little bit. But in the in
the treatment center in if you if you give a dirty urine you're gone. that's the route, you know,
so you have to really work with them, you have to really want to stay clean.”
P6 “Detox and addiction services were brilliant”
P6 “I think it needs a complete overhaul to be honest, like, you know, it [the services] needs a
proper structure really. But it's not being looked at”
P7 “there's no point me coming here and doing the detoxing going back to Stephen's green
hostel I said at this pointless...because there's no way I was gonna stay sober in the hostel”
P7 “the one at [name of place] was high threshold. there was no drugs or drinking allowed
in the place. Well people still went over the weekend, you know that way and came back in a
soberly manner, but did have a few drinks, you know?”
Key workers
P2 “You know, they're (key workers) very inexperienced, I think so anyway...they're 12 years
younger to me, honestly they don't know. I didn't I didn't benefit much, you know...I just got
the feel, I just got the feeling that they don't really care about you in whatever's going on. But
you can expect the experienced ones to care about it. And they do.”
P3 “There just wasn't enough staff to keep up with what was going on at the place, there were
too many residents. they had mental health issues but they were really violent to each other. I
was scared, scared at all times.”
P3 “But you know, that's the good the staff, they are very good in all the truth.”
P4 “I think they're brilliant, the staff.”
P5 “They did really help you very well...help me out on a personal level and yeah so I can't
really say anything bad about them you know? I can't say anything that they should have
done”
P5 “And also she would like, help you, see what you might need support with that they can
like simple things like opening a bank account like a post office account. so things like that,
whatever you need she'd help you with. she helped me register with the council because I was
never on the council the mainstream council”
P7 “the staff they try their best I think you know I think they're really good hearted people
and they want you to do well, you know, they try their best in that way. you can have a bit of a
laugh with them, have a chat and I've also had key workers there where I really needed
something to talk about as in you know, where I'm moving next or something like that, they've
always offered that you know that way. And they've always offered their support”
P7 “there was a lot of young people as staff members, you know, and I thought that many of
them had gone to college and then had you know gone to working and experiencing these
places, you know that way, just a lot of it was a you know could like, you know; they were
learning on the job which Is fair enough but a lot of them seem like they were out there to be
out of their debt.”
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D ISCUSSION
Most of the 7 participants were largely critical of the mental health, housing and social
services available to the homeless population in Dublin. All the three services were
highlighted during the course of the interview because all are interlinked, as discussed below:
Causes of mental illness: (Domain I)
The issue of high rents and lack of housing arose early in most interviews and therefore can
be taken to be a major cause of hopelessness and distress, 5 out of 7 (71.42%) rightfully
calling it the root of most homelessness, in addition to facing stigma from the society and the
administration itself (“I just thought it [accessing counseling] was something to be ashamed
of. Maybe I thought people would look down on me and think I'm silly.”). Major discomfort
is also brought by numerous "dehumanizing" rules imposed by hostels, hotels and
administrations, heavily limiting their social interactions and movements, including the
homeless population being disallowed to choose their doctors in case the particular doctor
that attends them “does not like you [them]”. Wrong assumptions made by people regarding
the cause of homelessness (addiction), which could be a result of lack of awareness also
disturb the already unstable mental state of the population, alongwith the incredibly low
quality of housing services where the premises are not clean and “there was vomit on the wall
and feces.” The entire scenario being remarked as “mentally it was awful.”
Resources: (Domain II)
A major loophole in administration was found to be the lack of links, support networks and
communication between the various parts of the administrations and homeless services, along
with contradiction of what is expected from the population by different bodies of
administration. There are no “wraparound services”: “every time you go somewhere you're
meeting somebody different and you know, it's like a lot of people fall through that, fall
through the cracks then”.
Misuse of available services is also prevalent, including abuse of prescribed mental health
drugs and social housing being owned by private landlords for commercial purposes, thus
depleting available housing resources. This is similar to profit-oriented privatization of
services, evident throughout an interview, making available resources difficult to access and
in turn exploiting the homeless for profit. A participant mentioned "Humanity kind of goes
out of the window when profit margins are lofty." The Dublin City Council has also been
accused of corruption and lack of transparency as to how social housing is allocated.
Many homeless and the vulnerable (eg. addicts) are malhandled, including "infantilizing"
them (which results in "institutionalization") and creating a chain of more "victims'' instead of
empowering the existing victims out of the distress and homelessness (“You’ll do better if
you act like a victim”, therefore “creating more victims”). This is majorly because housing
staff are not trained adequately (or unwilling to apply their training) in suicide and addiction
management and prevention (also likely because of the allegedly low staff to population
22
ration, tired staff). There is prevalent violence in the hotels, and those fighting addiction are
not provided with the chance of a stable environment during and/or after detox and treatment,
which pulls them back into addiction as a coping mechanism creating a vicious cycle.
Similarly, there is not enough care for those suffering from mental disorders.
In an interview, it was shocking to find that the staff of a certain residential service were
unmoved by even the death of a homeless person in their property. It is likely that lack of
empathy and care from some staff is noticed by the population. The staff are observed by the
population (7 out of 7) to be under-resourced: “The staff are at the top of their throat”.
Additionally, not being accepted into Dublin’s homelessness services due to country-side
belonging and extremely limited help for methadone addiction have further thrown many
from the population into crisis. It was mentioned that the “problem isn’t recognized enough”.
The pandemic observed virtual visits to a physician gaining preference, whereas the opposite
is true for mental health services (“it [online counseling] does not work”). The population is
also now more prone to consumption and increased struggles of those sleeping rough as help
from the community via means or money also considerably decreased during the pandemic.
A positive change that the dire conditions brought were, according to 2 of the participants,
the decrease in the number of people in a room which has been cut to half. The participants
claim to now have easier interactions and better living standards.
In similar sense, referrals are often not made correctly as a participant never had a helpful
social care worker or contact from a housing support team, and another participant expressed
disappointment over corporations meant to help her taking “advantage” of her deteriorating
mental health by not providing appropriate services. It was also pointed out that the pandemic
lockdown has negatively impacted the accessibility to mental help services and treatment,
and that there are very limited alternatives which can be accessed.
The participants had dim experiences with the staff and services for mental health. We found
that the staff were not always empathetic and kind, probably because they lacked support for
themselves when they are worn out which is a common observation in the field of mental
health. Additionally, most services are perceived to be "lip service", and are a "disgrace"
especially because they run on a "prison routine" and for profit. The services are also found
to be heavily biased towards addicts, which was interesting because previous studies claimed
the contrary, with 6 participants stating to have seen zero transparency as to how housing is
allotted or people prioritised. Housing support in levels above key workers was also called
unresponsive.
Beliefs (Domain III)
The participant believes (and is afraid) that homelessness is on the verge of normalization due
to the increasing number of people becoming homeless, which could be dangerous for the
homeless population as then not much effort would be made to curb the social problem,
especially because a harrowing lack of empathy is noticed in "bigger groups" which don't
have any "personal responsibility or care" in a “slow community”. Reasonably, the
participants ask for a “safe environment” as “addiction and homelessness don't happen in a
safe environment.”
23
One very interesting statement that a participant made was that educated people are
"encouraged" to have mental disorders; which means awareness about mental health
disorders encourages people to have these disorders. This could also be reframed as increase
in education/awareness makes people more thoughtful and thus vulnerable to mental health
problems.
A participant also finds addicts very "manipulative" for their own gains.
Stigma, as explained deeply by a participant, “always destroys people from inside, mentally.
Become almost numb and become a cold person...you turn cold and you don't wanna let
anybody in because you feel weakness.” Looking for help via services was deemed as being
“weak and vulnerable”.
There were two intriguing observations made regarding the homeless: that they were
"infantile" and that most are simply awaiting improvement in conditions instead of giving
efforts themselves to improve their own condition, and that most of the homeless population
is not trying to move on because of the easy availability of drugs as an easier coping
mechanism. A participant stated that most new and continuing homlessness is a result of this
addiction.
The participants’ beliefs about the government were not in a positive light, too. It seems to be
the "government's dream" to “bring in” workers at a low pay, which consequently deplete
jobs and housing available to locals as affordability decreases. The participant also finds it
interesting that whenever such issues are brought up, they are deemed "far righty or racist"
instead of evoking a question as to why the government is in partnership with those who are
only exploiting the resources of the country. There was a mention of businesses being
opportunists, which would shift the moment they find a better option, which is why attention
should be paid to the citizens first. The government doesn't care about the low paid workers
as the government "owns" them.
5 out 7 participants confirmed their beliefs of HAP and medical priority being the only two
ways to avail help from housing services, which themselves are again very hard to get (“I was
asking for help for years, about two or three years before I broke down”). Petty crimes are
also seen as a way to achieve temporary shelter by many of the homeless, who are not
supported enough to “break the cycle”. Some participants have a strong view that enhanced
therapeutic services are only "another clango" as the counseling services are never up to the
mark and are very loose, therefore mental health problems are a major reason for low
complete recovery from homelessness. Often, services are observed to have been “forced”on
the population instead of being encouraged to wholeheartedly accept them, leading to
stronger non-acceptance and stigma. One believes that because the student accommodations
have risen in "lightning speed", it is likely that some of them will be converted into homeless
accommodation in 10 years' time, while another states that “the whole system is a bit messed
up” as profits are made by keeping people on continued addiction (methadone) and out of
services.
Accountability (Domain IV)
Overall, 6 of 7 participants do not find either the government or the accommodation facilities
are taking account for their actions and policies. One finds it "disingenuous" that the
24
government talks about investing money into curbing homelessness while there are no visible
improvements, and complains that "homelessness has become an industry now", with "no
accountability for outcomes". This lack of accountability is encouraged by incidents where
personnel are not answerable or get any "deductions" when a homeless person dies at their
property, which shows that it doesn't matter if a homeless person is dead or alive. It was
unanimously agreed that the government can do much better and a major change should be
tackling homelessness due to lack of housing first, because it is in the government’s control
and responsibility. Once homelessness due to the housing crisis is a less serious problem, the
resources can be invested in areas not in the government’s control completely like addiction.
Mental health services (Domain V)
A participant prefers a private counselor that she pays personally as she does not approve of
the quality of homeless counselors otherwise available, while two others have expressed
preference to be helped by the same counselor throughout their journey, which is obvious
because having to build a rapport with a counselor or therapist repeatedly from scratch is not
a sustainable option.
4 out of 7 participants pointed out ways in which mental health services have supported them
in making positive changes in their lives: “I never woke up at five o'clock in the morning now
I'm making my business now to wake up 5 o'clock every morning, prepare myself yeah well I
do that the night before.” “...anyone that has any fear of counselling, I'll ask them to give it a
try, you know.” “I've learned to open up more”. However, one participant’s experience with
alcohol counseling (which she was forced into) was disappointing because nothing more than
marking the attendance happened. Obviously, such practices hinder any helpful outcome
(“There's no outcome”, “mental health is a joke”). This has blurred participants’ trust on
mental health services for the homeless, so much that they wouldn't be hopeful about the
prospect of accessing a new improved service. However, a participant praised the service he
received in a trauma-based therapeutic center, because “it was bringing up the past”, talking
about it, and was therefore very helpful.
6 out of 7 participants have expressed an aversion to having been prescribed medications as a
solution to their mental health struggles, and claim to want more focus on therapy and/or
counseling, in addition to having a necessary follow up after completing a mental health
support course, without which “you’re back to square one”, and therefore to avoid the net
result being zero, “needs to be a follow on to keep people off of from reentering into the
premises and into that cycle”. There were also multiple complaints on the waiting times to
gain access to the mental health services, which ranged from a month to about half a year, for
which many who wait for their turn “fall through the cracks of homelessness”. It was also
surprising to note one of the participants expressing concern over receiving no help unless
you’re “actually really mentally ill”, “they can put you on medications which they did”.
Overall, there was unanimity over the fact that not enough resources are being invested or
planning going into structuring the mental health services for homeless mental health. It was
25
agreed that mental health “definitely needs to be more of a priority, the same as mental health
needs to be more of a priority, in country like more money more funding needs to be put into
this but it's not.”
Improvements (Domain VI)
The participants clearly suggested a few potential improvements that can improve outcomes.
The foremost improvement is improving housing services by providing affordable housing,
that was claimed to get rid of 99% of all the problems, including mental health problems that
arise from the distress of not having a stable base. Additionally, the lease length should be
increased from one year to at least two or three years to a maximum of 5 years, but of course
on the condition of decent living: “Obviously, if you're wrecking the house you can throw me
out, but if you're paying the rent, not for them just to be able to turn around for a profit. If you
if you'll keep that place to a standard, and paying the rent on time, there's still people being
thrown out on the streets because the landlord doesn't want the house, he wants to sell.”
A helpful scheme would be gauging if the homeless person can afford rent for a certain
period of time and then helping them find an accommodation for the specified span of time.
When told that there were a few organizations that worked close to this suggestion, a
participant answered that there is no actual support after the gauging. Additionally, there
should be more long-term accommodations and emergency short-term accommodations
which provide a “stable base to work on”, being unanimously deemed most important during
and after treatment and release from prison, and for breaking the “vicious cycle” of
homelessness.
The allowance for people to be able to own social housing is problematic as it leads to
privatization, and should be cancelled. Segregation of hostels for different categories of
addiction, though called “hard” and “not happening” based on the current progress rate of
services, was pointed out to be extremely helpful because according to a participant “I had
taken drugs in the hostels which I've never taken before. So to say to have the two (drugs and
alcohol) of them separated would be a lot better because you know, even people that don't
have addictions went into these hostels end up drinking and taking drugs”. It was also
suggested that it would be extremely helpful if the staff could go around and interact with
those sleeping rough “to make sure that they understand that they're human beings” and in
doing so providing them with options for help. This was probably suggested because of the
fact that there are many homeless people who feel vulnerable and stigmatised to be asking for
help as discussed previously and so choose to not seek support. Similarly, there should be
increased homeless suicide supports with information that is “easy to hand on”.
Finally, stress was laid on decentralization of services from Dublin, including mental health
services and housing. There are "a lot of places where you can stick houses" and therefore
having concentrated in Dublin is "stupid". Also, “each county in the country should have
their own emergency services. and then maybe that might take a bit of pressure off people
coming to Dublin and you know...but they had no other option when there's nothing down the
country and people are looking for help”. It was sad to hear the struggle of especially those
who belong to a county other than Dublin as they are not allowed to register with Dublin
homeless services for access and are asked to register in their respective counties where there
26
are almost no services available. For this reason, it is important to spread the services equally
all over the country.
Staff and Services (Domain VII)
Initially, accessibility of the services was discussed and major issues in the accessibility of
homeless services were discovered. A participant stated that it is not possible to access
services without medical cards, which could be due to the priority that the medical card gives
in the long wait times (which in itself is an accessibility hurdle - “I was trying to get into
detox I was, it was like it was nearly a year trying to get in. A really long waiting list - some
people kind of give up hope or they lose motivation - anything can happen in that length of
time”). There also seems to be a lack of knowledge of available support is also a big hurdle to
accessing services, a participant mentioning “You may be homeless for more than 3 years
before they can help you” and “there's lack of information in the community that need the
services”. On a similar tone, teenagers who become homeless also have very limited
exposure to what resources are available for them, and available help for them, in fact, are
extremely limited. Accessibility is also greatly reduced to homeless population from counties
other than Dublin due to absence of services in the counties (“For me to access services like
methadone clinic and stuff like that, I had to travel to Dublin [from Carlow] and there there's
only two buses a day like you know, so and then there's also somebody might not have
money to travel”), which is often perceived as discrimination (“It's really lacking I think
down the country you know, and even for, even for follow-on like there's eight houses here
and they hold two people each the 16 people that are secured accommodation for two years,
like that's only 16 people.”) For specifically counseling services, seeking Garda as the lawful
guardian to seek counseling is another barrier, a participant preferring to “cry and get
comfort” than to actually go through the process. Homeless mothers also seem to have very
limited accessibility to services due to the lack of child care services in collaboration with
homeless services: !in the country - one treatment center that will take mothers, and their kids
have to be under a certain age as well. I think to take them up into four or five.” On the other
hand, accessibility is easiest for male adults who have lived in Dublin for a long time as they
fit the criteria to be given all the services in addition to having information about the services
(“It was easy for me because I was in town...I know it can be difficult for some people and it
could be difficult for me as well, but I think I was just lucky they (connections) worked out
good”)
We then moved on to initiation of the services, where it was found that the engagement
within services was pretty low and that the participants were initially not a part of any support
network, which made the participants feel isolated and confused regarding the expectations of
the services from them, which was a “a bit traumatic”. As has been discussed earlier, having
the knowledge that to access housing support after detox and treatment one needs to belong
to Dublin is yet another obstacle, otherwise which people go back to being homeless after
detox, which does not make sense. If they need to access housing support in the county, they
will have to repeat the treatment procedure regardless, which themselves are hard to get into
for their low numbers. It is, in fact, “hard to register as homeless in Dublin” itself.
27
Moving on the quality of staff and services, mixed experiences were found, where though
most services were perceived to be below average, the staff were appreciated by most
participants to be doing the best that is possible (“the staff are good in all truth”, “they have
saved so many people sleeping rough, so much of hard work”, “brilliant staff”, “helped me
out on a personal level”, “the staff they try their best I think you know I think they're really
good hearted people and they want you to do well... they’ve always offered their support”).
However, the staff were termed as “rude” by one participant, and the low standards of hostel
services was echoed by all participants. The difference in views regarding the staff could be
because of the difference in “standards”, with new inexperienced staff faring (obviously)
worse than old experienced staff (“You know, they're (key workers) very inexperienced, I
think so anyway...they're 12 years younger to me, honestly they don't know. I didn't I didn't
benefit much, you know...I just got the feel, I just got the feeling that they don't really care
about you in whatever's going on. But you can expect the experienced ones to care about it.
And they do”). The difference could also result from the staff being overwhelmed as the staff
to service residents ratio is clearly very low despite the residents having mental health issues
and being violent. There were also complaints that things went wrong when staff “don’t have
the qualifications to here”. Hostel environment was called “bad” and “cold” to the extent that
“it would effect your mental health, physically emotionally, mentally especially”. Multiple
participants talked about the bullying, drug abuse and prostitution that are prevalent in the
hostels, calling it a “joke” and claiming that “You have to carry weapons, just to protect
yourself at that place”. A participant “would be in the streets than to be in them” because “it's
safer on the streets” with the CCTVs, which is shocking. Because of the prevent drug abuse
in the hostels, a participant finds no justification for someone to stay ina hostel while
undergoing treatment and/or detox as it would never be of use. A participant claims that
“them hostels, should be, closed. Let someone from the services go and spend a week
themselves. They'll never go, it's that bad there. They're not safe for anybody”.
Group sessions were unanimously echoed as being extremely helpful as it not only helped
participants realise that they were supported, but also was an effective way of letting people
make a positive connection and friendship. In fact, for many participants, the only friends
they had were the ones they met during a group session somewhere after losing their older
friends due to reasons related to their ongoing episode of homelessness. This was called a
“life-changing experience” which made the participants “hopeful of the future”. Detox and
addiction services were also called “brilliant” by a participant.
It was also found that there is no compulsion in the day programs to “stay clean”, whereas the
opposite is true for residential treatment centres. The day programs, therefore apparently, lose
their value due to this leniency. However, high threshold residences as well tend to overlook
“weekend drinking” if people “come back in a soberly manner”. This again, similarly, makes
such settings less effective. Overall, it was agreed that services need a “complete overhaul”
and better “structure” to be effective for the homeless population.
28
RECOMMENDATIONS
In addition to the improvements already suggested by the participants in the “Improvements”
domain, I would like to suggest a few more recommendations based on the discussions had:
1. More resources should be invested in housing and maintenance of the same, both
social housing and individual housing. Regular inspections should also be conducted
in social housing as a part of maintenance.
2. Abolishing inhumane rules followed in the hostels and making sure that the homeless
population is treated with decency and respect.
3. Reduce prescribing medications because they clearly sometimes turn into addictions.
Also, medications are not even preferred. Medications, as far as possible, should be
replaced by therapies and counseling. Wherever medications are prescribed, stricter
control on availability and use should be incorporated.
4. Links and effective communication between the different parts of the homelessness
services, whether within a support organization or between organizations, should be
strengthened, so that someone opts for a different service or a different organization,
he or she does not fall in the cracks of miscommunication and weak links, which
cause long delays.
5. Staff clearly need more support via training and more resources
6. Drug dealers entering recovery houses should be prohibited and an appropriate
security system should be maintained alongwith frequent inspections.
7. Transparency is highly required when dealing with the homeless population as it
considerably decreases hopelessness during wait times. Therefore, it is suggested that
staff be transparent in exchanging information with the homeless population regarding
housing wait times or other important matters so that it does not cause confusion or
depreciation of the person’s mental health or, for that matter, physical health,
8. Disseminating awareness and information on homelessness is important to decrease
stigma and uncomfortableness in the society regarding homelessness. Awareness
amongst the homeless population is also important to decrease the stigma in asking
for and accepting help.
9. The homeless population that is stuck in the cycle of petty crimes and related
addictions need special attention in terms of focus on therapy and counseling to
“break the cycle”.
10. It is important to have adequate and defined follow-up or “wraparound” services after
a person has completed treatment or therapy to decrease rates of relapse, which
currently evidently is quite high as pointed out by many of the participants.
11. Trauma-based therapy is found to be very effective and it can be suggested that the
access to such therapies and counselors be increased amongst the homeless population
going through treatment. Additionally, the much appreciated effectiveness of group
therapy should be maintained.
12. Weekend substance consumption need to be taken seriously at residences, especially
at high threshold residences.
29
13. A balance should be struck between experienced and inexperienced staff in the
homelessness services, so that inexperienced staff get enough guidance while they are
learning at work and the homeless population seeking help do not perceive any major
shortfall while accepting services.
14. It needs to be realised that teenage homelessness is a serious existent and overlooked
issue, and more services and awareness needs to be available regarding the same.
15. Similarly, and as pointed out in discussions, services for mothers need to be improved
and made more accessible, by providing more child-care facilities and mother-centric
services. Priorities should also be set on similar lines.
30
REFERENCES
Websites:
Focus Ireland; “About Homelessness”; retrieved on 15th March, 2020 from
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Dublin Region Homeless Executive; (April 25th, 2009); “NATIONAL QUALITY
STANDARDS FRAMEWORK FOR HOMELESS SERVICES IN IRELAND”; retrieved on
15th March, 2020 from https://www.homelessdublin.ie/content/files/NQSF-Standards.pdf
Rebecca Murphy, Kate Mitchell and Shari McDaid; June, 2017; “Homelessness and Mental
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homeless service with mental health issues”; Irish Examiner; retrieved on 14th March, 2020
from
https://www.irishexaminer.com/breakingnews/ireland/increased-crisis-interventions-reported-
as-more-people-visit-homeless-service-with-mental-health-issues-922842.html
Journal papers:
Lydie A. LebrunHarris, Travis P. Baggett, Darlene M. Jenkins, Alek Sripipatana, Ravi
Sharma, A. Seiji Hayashi, Charles A. Daly, Quyen NgoMetzger (07 November 2012);
“Health Status and Health Care Experiences among Homeless Patients in Federally
Supported Health Centers: Findings from the 2009 Patient Survey”; DOI:
https://doi.org/10.1111/1475-6773.12009
Prinsloo, Bernice and Parr, Catherine and Fenton, Joanne (2012); “Mental illness among the
homeless: prevalence study in a Dublin homeless hostel”; Irish Journal of Psychological
Medicine , 29 , (1) , pp. 22-26.
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perspectives of at-risk youth”; Child and Adolescent Social Work Journal; 20, 529548. DOI:
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Howard H. Goldman, Joseph P. Morrissey, Robert A. Rosenheck, Joseph Cocozza, Margaret
Blasinsky, Frances Randolph, and the ACCESS National Evaluation Team (2002) “Lessons
From the Evaluation of the ACCESS Program”; Psychiatric Services 53:8, 967-969
Robinson C (2002); “I think home is more than a building: Young home(less) people on the
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ResearchGate has not been able to resolve any citations for this publication.
Article
OBJECTIVE: To describe sources of health care used by homeless and housed poor adults. DESIGN: In a cross-sectional survey, face-to-face interviews were conducted to assess source of usual care, preferred site of care for specific problems, perceived need for health insurance at different sites of care, and satisfaction with care received. Polychotomous logistic regression analysis was used to identify the factors associated with selecting non-ambulatory-care sites for usual care. SETTING: Twenty-four community-based sites (i.e., soup kitchens, drop-in centers, and emergency shelters) frequented by the homeless and housed poor in Allegheny County, Pa. PARTICIPANTS: Of the 388 survey respondents, 85.6% were male, 78.1% African American, 76.9% between 30 and 49 years of age, 59.3% were homeless less than 1 year, and 70.6% had health insurance. MAIN RESULTS: Overall, 350 (90.2%) of the respondents were able to identify a source of usual medical care. Of those, 51.3% identified traditional ambulatory care sites (i.e., hospital-based clinics, community and VA clinics, and private physicians offices); 28.9% chose emergency departments; 8.0%, clinics based in shelters or drop-in centers; and 2.1%, other sites. Factors associated with identifying nonambulatory sites for usual care included lack of health insurance (relative risk range for all sites [RR]=3.1–4.0), homelessness for more than 2 years (RR=1.4–3.0), receiving no medical care in the previous 6 months (RR=1.6–7.5), nonveteran status (RR=1.0–2.5), being unmarried (RR=1.2–3.1), and white race (RR=1.0–3.3). CONCLUSIONS: Having no health insurance or need for care in the past 6 months increased the use of a non-ambulatory-care site as a place for usual care. Programs designed to decrease emergency department use may need to be directed at those not currently accessing any care.
Article
Studies suggest that only a small number of young people with diagnosable mental health difficulties are referred for treatment. Of these a significant proportion fail to engage in treatment or terminate prematurely. This situation is exacerbated when the young people are homeless or at risk of homelessness, and considered to be at-risk. With this at-risk population the process of engagement is likely to be a critical aspect of successful interventions. Using qualitative methodology, at-risk clients of a mental health service (n = sixteen) were interviewed, and four primary themes crucial to the engagement process were identified. The data indicated the importance of considering the young person and their multifarious life-experiences; the attractiveness and accessibility of the service; and the follow-up offered by the service provider. The implications for mental health services that provide counseling for young people are discussed.
Article
Clients' and providers' perceptions of clients' needs were compared in 18 community treatment programs participating in the Access to Community Care and Effective Services and Supports program of the Center for Mental Health Services, a national demonstration project on treatment of homeless persons with mental illness. The study sought to determine whether perceptions differed and whether assessed needs for services were related to service use. A total of 1,482 clients contacted through community outreach who entered the case management phase of the program after an average of 32 days were given an evaluation interview at entry into the program. The clients and outreach workers identified clients' needs in seven core domains-mental health, general health, substance abuse, public financial support, housing assistance and support, dental care, and employment. Use of related services in the 60 days before the case management evaluation was determined. The greatest differences between clients' and providers' perceptions of service needs were in dental and medical services, which were more frequently identified as needs by clients, and in substance abuse and mental health services, which were more frequently identified by providers. Clients' and providers' assessments of need were significantly, but not strongly, correlated with each other, and both were correlated with use of mental health and substance abuse services. Mental health service providers are less likely than clients to identify needs for services other than mental health services. Service use, at least in the short run, is related to both clients' and providers' assessments of need.
Dublin Region Homeless Executive
Dublin Region Homeless Executive; (April 25th, 2009); "NATIONAL QUALITY STANDARDS FRAMEWORK FOR HOMELESS SERVICES IN IRELAND"; retrieved on 15th March, 2020 from https://www.homelessdublin.ie/content/files/NQSF-Standards.pdf
Increased crisis interventions reported as more people visit homeless service with mental health issues
  • Noel Baker
Noel Baker (8th May, 2019); "Increased crisis interventions reported as more people visit homeless service with mental health issues"; Irish Examiner; retrieved on 14th March, 2020 from https://www.irishexaminer.com/breakingnews/ireland/increased-crisis-interventions-reportedas-more-people-visit-homeless-service-with-mental-health-issues-922842.html Journal papers:
Health Status and Health Care Experiences among Homeless Patients in Federally Supported Health Centers: Findings from the
"Health Status and Health Care Experiences among Homeless Patients in Federally Supported Health Centers: Findings from the 2009 Patient Survey"; DOI: https://doi.org/10.1111/1475-6773.12009
Frances Randolph, and the ACCESS National Evaluation Team
  • H Howard
  • Joseph P Goldman
  • Robert A Morrissey
  • Joseph Rosenheck
  • Margaret Cocozza
  • Blasinsky
Howard H. Goldman, Joseph P. Morrissey, Robert A. Rosenheck, Joseph Cocozza, Margaret Blasinsky, Frances Randolph, and the ACCESS National Evaluation Team (2002) "Lessons From the Evaluation of the ACCESS Program"; Psychiatric Services 53:8, 967-969