Housing, Health and the Individual

The Mental Health Needs of Homeless People

Wayne Simmons, Training Officer with Housing Rights Service, discusses the limitations of the law on homeless people and mental health. He pays tribute to the work done by charities in addressing complex needs.

Mental Health has been defined as ‘the emotional and spiritual resilience that enables us to enjoy life and to survive pain, disappointment and sadness …’ (Investing for Health: Promoting Mental Health Strategy and Action Plan 2003-2008). It affects how we view ourselves and interact with others.

There are various forms of mental illness, affecting people of all ages. Symptoms range from mild to severe. One in four people will suffer from poor mental health (WHO, 2001), with around 158,000 people treated, in Northern Ireland, each year (Accept Northern Ireland 2000).

A needs analysis carried out in 2003-2004 by the Northern Ireland Housing Executive indicates that mental illness has a profound effect amongst homeless applicants in parts of Northern Ireland. 64 per cent of those who presented as homeless had support needs and 56 per cent had multiple support needs. Mental health was the second highest category of support need identified.

The law

The Mental Health (Northern Ireland) Order 1986 (as amended) covers the assessment, treatment and rights of people with a mental health condition.

The Disability Discrimination Act 1995 (DDA) recognises that various barriers exist within society that may present practical difficulties for disabled people (including those affected by mental illness). Discrimination, according to the legislation, can be direct or indirect. Indirect discrimination applies to the provision of a variety of goods and services, both public and private – including housing services.

However, the impact of the legislation could be criticised, with regards to its provision on the housing needs of those with a mental health condition as well as its active exclusion of those with a personality disorder or dual diagnosis.

The DDA in action

Two recent housing cases have had a tremendous impact upon the interpretation of the Disability Discrimination Act in relation to housing.

The Lewisham v Malcolm (2008) UKHL case related to Mr Malcolm, a secure social tenant with Lewisham Council, who breached his tenancy agreement by subletting. In December 2004, the council issued possession proceedings. Mr Malcolm’s defence against the possession referred to Part III of the DDA. He argued that his decision to sublet the flat related to his mental illness. To reposs-ess the property would be discrimination.

Evidence from Mr Malcolm’s psychiatrist and social worker both confirm-ed that, at the time he sublet his property, he had stop-ped taking his medication and was unlikely to have fully understood the con-sequences of his decision.

At county court, the judge stated that, although Mr Malcolm was to be defined as disabled under the DDA, his decision to sublet was not related to his disability. The Court of Appeal overturned the county court decision. However, the council appealed successfully to the House of Lords, who accepted that while Mr Malcolm was to be defined as disabled under the Act, the possession pro-ceedings should not be considered as ‘disability discrimination.’

As Baroness Hale (a dissenting Law Lord with regards to the Malcolm case) states, this type of decision making: ‘raises questions about the fundamental principles underlying discrimination law. Is it intended simply to secure that disabled people are treated in the same way as other people who do not have their disability? Or is it intended to secure that they are treated differently from other people in order that they can play as full as possible a part in society whatever their disabilities?’

The CDS Housing v Bellis (2008) case (EWCA Civ 1315) confirmed this application of the DDA. Mr Bellis, a secure tenant with CDS Housing, suffered from a delusional belief that his tenancy’s central heating system was emitting radiation. Mr Bellis interfered with the system, damaging it on two occasions. The county court granted CDS outright possession, the court of appeal agreeing despite medical evidence of an improvement in Mr Bellis’ condition.

While both cases relate to eviction, the precedent could apply throughout all statutory provision of housing.

Dual diagnosis

The legislation actively excludes those with ‘personality disorder’ and/ or ‘dependence on alcohol and drugs.’ This may affect the assessment for social housing of individuals with dual diagnosis (ie, a diagnosis of mental ill health alongside alcohol/substance misuse) and/or personality disorder. Although vulnerable, they may not be seen as in priority need by the Housing Executive because their condition is not seen, legally, as mental ill health.

The Seeds of Exclusion 2009, a report carried out by the Salvation Army, highlights ‘too many victims of an excessive drinking and drug culture that… leads and keeps people amongst the most socially excluded in our society.’

Clinical assessment showed that 80 per cent of all respondents had drug and/or alcohol misuse problems, alcohol dependency being highest among respondents in Belfast (74 per cent). Almost three-quarters (74 per cent) had multiple psychological problems. However, less than a quarter (24 per cent) were receiving medication and less than 15 per cent considered they were receiving appropriate medical care. Levels of attempted suicide in Belfast were three times higher (approximately 40 per cent) than in London.

Responding to the needs of each individual

While statutory agencies and housing providers are seen to operate under specific direction of legislation, the voluntary sector is less inhibited. Dynamic supported living is provided by several mental health charities, alongside floating support – an invaluable service tailored to meet the needs of clients in their own home, helping them to retain their accommodation.

Extern’s Multi-Disciplinary Homeless Support Team (MDHST) works specifically with people with complex and multiple needs (including dual diagnosis and personality disorder), regardless of whether they are street homeless, living in a hostel or maintaining a tenancy. Practical and emotional support is offered along with assessment, care planning, liaison and advocacy.

The Salvation Army provides a range of innovative support in Belfast, including a direct access night shelter, offering a meal and a bed for the night to street homeless men. This can be the initial contact with an individual leading a chaotic lifestyle marked by alcohol or drug misuse, symptomatic of dual diagnosis and/or personality disorder. It also runs a registered unit, offering supportive housing to men with mental illness. More recently, two projects have been developed to motivate and engage such clients through Tai-Chi and gardening.

The Welcome Organisation gives invaluable assistance to homeless individuals and rough sleepers in Belfast. Services include a daytime drop in centre providing for the basic needs - food, showers, laundry and recreation, street outreach programmes and night time crisis accommodation - of vul-nerable women with very complex needs. People who are dually diagnosed with severe mental illness and alcohol/substance misuse disorders now constitute over 60 per cent of the Welcome Organisation’s clients.

Conclusion

The voluntary sector demonstrates a commitment to work with a client group often unable to access statutory support. As Sandra Moore (Director of Homelessness Services at The Welcome Organisation) states ‘Few statutory services appear to understand or address the particular needs, characteristics and treatment of this particularly vulnerable sub group – most of whom display very complex needs ...’

Through the voluntary sector’s ongoing commitment and flexibility, the most vulnerable of the homeless – those with both mental health and substance misuse issues - are able to access services which may otherwise be denied to them under the legislation.

The challenge lies with the statutory sector and legislation to consider the needs of the individual, as opposed to actively excluding a client group which is becoming further isolated and increas-ingly prone to homelessness.