by Dr. Paulann Grech, Department of Mental Health, Faculty of Health Sciences
It has often been described as the island of ‘sun and blue skies’. So it is, with our long lazy summers and a short winter that, at its worst, still allows the sun to smile through on most days. The people of Malta have been portrayed as being friendly, generous, witty and loud – even our car horns seem to exceed the acceptable decibel range, especially when honked in the middle of the night to express righteous indignation! Yet beneath this vibrant carnival of colours and expressions lies a somewhat sordid reality that is still relatively unexplored, partly due to a lack of awareness but perhaps also brought about by a tendency to ‘sweep dirt underneath the carpet’, ignore that which bothers, make-do and trudge along. Alas, over the recent years, a number of factors, especially the rise of the social media empire, have given a voice to those who have been mute for long decades. Two notorious issues that have slowly but surely crept out of their hiding place are those of mental health and homelessness. Typically addressed as separate areas, both have been traditionally placed at the bottom rank of the societal ladder, best dealt with by donning a pair of blinkers and focusing on the more glamorous aspects of life, thus effectively rendering these issues invisible. Mostly, invisibility refers to limited resources, in particular financial and human ones, that are specifically dedicated to address such causes.
Mental health care
To this extent, Mental Health Care has often been described as the ‘Cinderella’ of health services. If so, the issue of homelessness can then definitely be considered as the ‘Ugly Duckling’ of society. A look at the past five years shows that public attention has been captured by shocking images of the state of mental health services in Malta. The description of such services as being a throwback to Victorian times (Dalli, 2016), as well as the purported suboptimal working and living conditions at Mount Carmel Hospital have exposed what has been regarded as one of ‘Malta’s dirtiest secrets’ (Diacono, 2018). On a parallel level, the issue of homelessness, similarly regarded as ‘the best kept secret in Malta’ (Vakili-Zad, 2006) has been placed under the spotlight. Pictures of migrants sleeping on wooden pellets and using make-shift alfresco showers started to clutter the local newspapers. The death of a homeless Somali man underneath the Marsa bridge was also crucial in highlighting the potential consequences of being homeless even if living in the relatively safe island of the ‘sun and blue skies’.
So what happens when these two worlds collide and the homeless become mentally ill or the mentally ill become homeless? Unfortunately, the resulting picture is not a pretty one at all. Perhaps one should first acknowledge the fact that there is a reciprocal link between mental health and homelessness which, in a seemingly chicken-egg scenario, seem to be inextricably linked to each other. This is not really hard to discern because, more than anything, homelessness is a psychological state and not just a physical one. This is even more compounded by its invisible status. Thus, feelings associated with homelessness such as fear for physical safety, survival anxiety, shame, anger and loneliness are major threats to a person’s mental wellbeing.
Consecutively, suboptimal mental well-being may very well disrupt a person’s ability to carry out the essential aspects of daily life such as attending to one’s personal hygiene, taking the necessary precautions against disease and, more alarmingly, the ability to make good decisions. This combination of factors can present major challenges in obtaining/keeping employment and a residence. Conclusively, the poor mental health itself will then act as a powerful catalyst in keeping the individual literally stuck in a rut and being pulled in all directions by the forces of his/her mental difficulties, poverty and the homeless state. Non-local research on the link between mental health and homelessness exists. For instance, a 2009 systematic review by Fazel et al. explored the estimated prevalence of mental disorders in a total of 5,684 homeless individuals based in the US, UK, mainland Europe and Australia. Their main finding was that the prevalence of serious mental disorders was raised in comparison to the expected rates in the general population. Similarly, in another systematic review by Hodgson et al. (2013), the prevalence of psychiatric problems among young homeless people ranged from 48% to 98%, indicating that at least half of these youngsters had a clinical psychiatric diagnosis.
Local statistics are scarce
One may wonder whether similar results would be obtained if research in this area had to be carried out in Malta. Whilst local statistics regarding the number of homeless people in Malta are scarce, the existing ones provided by authorities have been harshly criticized as being an inaccurate representation of reality, mainly due to a definition of homelessness that is too narrow. Thus, as an example, defining homelessness as merely being out on the streets automatically omits those living in inadequate housing and in institutions. Whilst there seem to be no local official statistics on the link between homelessness and mental health, a look at the most recent electoral register shows that 55 individuals have their ‘home’ address listed as Mount Carmel Hospital. This leads one to question why these people have to seemingly resort to declaring that ‘home’ is a psychiatric hospital. Whilst I am sure that a myriad of different answers can be provided to this question, speculations may shed some light. Perhaps some of these 55 individuals are those who we term as ‘chronic patients’, referring to the ones who have been institutionalized for decades.
Let us not forget here that the local psychiatric hospital’s patient discharge rate has been officially reported to be lower than the average in the EU, whilst the patient’s length of inpatient stay remains one of the highest (Ministry for Health, 2018). These two facts, brought about by many factors, may very well be contributing to psychiatric chronicity and possibly dependence on the psychiatric system, to the extent that the hospital becomes one’s permanent home. Some of these 55 individuals may also be the ‘revolving door’ patients who are seemingly stuck in the dreaded vicious cycle of receiving treatment; getting discharged; failing to make ends meet and getting re-admitted to the psychiatric hospital. In particular, one has to mention those individuals who have addiction problems such as substance misuse – invariably these have the added burden of being even more stigmatized than sufferers of other mental illnesses such as depression or anxiety disorders. To this extent, substance misuse has featured in many studies and is considered as being one of the most common causes of homelessness, irrelevant of whether the addiction was initially triggered by homelessness or the actual cause of it (National Coalition for the Homeless, 2009). Upon reflection, such a link is quite understandable since in many cases of homelessness, survival is more important than anything else. If survival requires being in a permanent state of intoxication to nullify one’s emotions, then so be it.
Conclusively, one may wonder whether the Cinderella-Ugly Duckling combo of homelessness and mental illness can ever somehow transform into a stunning princess and a gracious swan. Well, an instant magical fix would require a potent Fairy Godmother with a turbo wand – since these seem to be quite short in supply, the notion of immediate change can be simply ruled out.
Primarily it must be acknowledged that the needs of mentally ill people experiencing homelessness are similar to those without mental illnesses; physical safety, education, transportation, affordable housing and affordable medical treatment. It is not very useful to assess and attempt to ameliorate an individual’s mental state if they do not even know when their next decent meal is going to come along. Thus, physical and mental needs have to be addressed simultaneously.
A wise man once said that ‘the first step toward change is awareness. The second step is acceptance.’ (Branden, 1986). Whilst statistics and theoretical speculations provide some mileage to raising awareness on the topic, let us not further depersonalise the homeless (and possibly mentally ill) person by excluding them from discussions on themselves. It is time to give a voice back to these people. It is time for research to be carried out with them and not on them. We need to focus on research that elicits narratives which convert ‘yet another homeless person’ into ‘Rebecca – the young single anxious mother of two who has just lost her job and is risking being kicked out of her rented apartment’. Such research may help Gerald, the pensioner, to describe the physical and emotional torture that he is enduring in trying to keep up appearances whilst knowing that he will probably not be able to pay the water and electricity bill. And who knows… anyone can be the next Rebecca or Gerald… mostly it boils down to luck/faith and/or the status or intelligence. The tables can indeed turn very quickly.
Branden, N. (1986). The Psychology of High Self-Esteem. USA: Nightingale Conant
Dalli, K. (2016). Malta’s Mental Health system is a throwback to “Victorian-style” services. Times of Malta. Retrieved from: https://www.timesofmalta.com/articles/view/20160130/local/maltas-mental-health-system-is-a-throwback-to-victorian-style-services.600563
Diacono, T. (2018). I’ve worked at Mount Carmel and the situation is horrendous. Lovin Malta. Retrieved from:https://lovinmalta.com/news/news-breaking/ive-worked-at-mount-carmel-and-the-situation-is-horrendous
Fazel, S., Khosla, V., Doll, H., & Geddes, J. (2008). The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS medicine, 5(12), e225. doi: 10.1371/journal.pmed.0050225.
Hodgson, K. J., Shelton, K. H., van den Bree, M. B., & Los, F. J. (2013). Psychopathology in young people experiencing homelessness: a systematic review. American Journal of Public Health, 103(6), e24-e37.Retrieved from https://www.nationalhomeless.org/factsheets/Mental_Illness.pdf
Vakili-Zad, C. (2006). Counting the Homeless in Malta. Journal of Housing and the Built Environment. 21(2), 141-157. https://doi.org/10.1007/s10901-006-9039-4
Ministry for Health (2018). A Mental Health Strategy for Malta 2020-2030 – A Public consultation Document. Retrieved from: https://deputyprimeminister.gov.mt/en/Documents/National-Health-Strategies/Mental_Health_Strategy_EN.pdf