The
European Project “Santé Mentale et Exclusion Sociale”
SMES-EUROPA "Mental Health and Social Exclusion" is a
limited contribution to the actions and initiatives in
several large European cities in favour (defence) of those
frequently forsaken, i.e. the
severely mentally ill who
become homeless street-dwellers and also vice-versa.
Among the poor they are the most vulnerable, prone to
further mental disorders and diseases.
A strong relationship exists between “social problems -
health problems”, “extreme poverty - social
exclusion” and “homelessness - mental illness”.
The experience acquired working in this field[1],
meetings with staff and agency representatives in major
European cities, the some European seminars on “Mental
Health and Social Exclusion”, the conclusions of
the “Preliminary
MHSE Survey” and
of “Health and Dignity” research/action, the direct
contacts (visit and exchanges) with divers projects in many
European metropolis realised with “Dignity and Health 5
Projects”, the participation in divers Erasmus
projects, amply demonstrate that successful actions and
programmes of prevention, treatment, and rehabilitation have
to be based on a double-sided approach where social aspects
go alongside health considerations to achieve the overall
well-being of an individual.
Aims and Objectives of MHSE Project
1. Promote
an awareness in society as a whole, and
more specifically among social and health
workers, politicians and the public at large
regarding the “de facto” loss of
access on the part of the homeless & mentally
ill, (abandoned on the streets, in their own
home, in psychiatric institutions), to basic
health and social services which should be
theirs by right.
2. Promote
the “Human Right”, the most fundamental
and indisputable rights which should guarantee
all human beings access to all basic social and
health services.
3. Emphasising the
link between social
precariousness (exclusion
& extreme poverty) and disease (in
general health and particularly in mental
health).
4. Facilitate
meetings, seminars and exchange programs
between professional
and voluntary people working in exclusion field,
with the express aim of exchanging ideas and
relating experiences and know-how on such topics
as promoting the continuous learning and
training of staff and sharing projects.
5. Promote
collaboration by setting up a European
MHSE network which will act as the promoter of
structured and coherent projects on the streets,
in shelters for the homeless and in work
rehabilitation centres.
6. Promote
analysis and evaluation, based
on research-actions and exchange programmes, of
co-operation between social and health sectors
both in the areas of identifying needs and in
setting up prevention, rehabilitation and
inclusion programs.
The “mentally ill homeless” of any sex and age (increasingly
young, though) may reach a state of total marginalisation
and lose their rights as citizens.
They do not benefit from solidarity or social security and
are forced to live in a state of total neglect, as their
presence in subway, train stations or in the street show.
Stripped of their dignity, they appeal to each and everyone
of us: paid and unpaid staff, policy makers and the general
public; we are all reminded of a fundamental “human
right”, i.e. human dignity. These completely “useless”
people are not the object of avant-garde psychiatric
treatment, nor is their be rehabilitation considered through
carefully studied training / rehabilitating programmes, for
they are “mentally ill” rough sleepers frequently forsaken
or undesired.
These outcasts are an epiphenomenon of an overall
degradation process. The unbearable sight of these
marginalised people point at the central core of society,
they are an exaggerated projection of the latter's state. A
line joining those on the fringes and
those at the centremight
easily be traced showing substantial continuity. Even if the
role of pangs of conscience, pity or patronising attitudes
cannot be denied, they are not the true cause for action. It
is a question of “rights” and “obligations” and
three considerations must be given priority:
Reaffirming personal dignity and human rights
The outrageous scenes in some highly industrialised
countries in the world are urgent appeals to enforce the
respect of basic human rights of the homeless and of those
living in families or institutions. Their rights are often «tramp»led
upon in the name of the much-acclaimed freedom of the
individual or simply because of red tape.
Preferring innovative and alternative projects
The scale of the problem and the ineffectiveness of mere
“assistance” in the long run call for medium/long term
innovative and alternative projects. Individuals must be
seen as people having rights, needs and living in a context
where the social/health private and public sectors interact.
Promoting urgent prevention measures
Unless there is prompt intervention into the causes from
which the process originates, the present crisis in the
welfare system will inevitably deepen, with disastrous
consequences for the young and all those in greatest need.
2.
Relationship between : poverty - social exclusion homelessness - mental illness
|
Marginalizing and exclusion processes are rarely
deliberately “chosen”, they are sometimes merely
endured, and all too oftenimposed in
the name of certain social standards. Progressive
marginalization has very serious consequences for
the most vulnerable in society. Such consequences
may manifest themselves as follows:
- Joblessness and homelessness;
- Family instability;
- Onset or deterioration of diseases;
- Failure in health and social security
rights;
- Loss of points of reference and
dissolution of social links;
- Definitive loss of identity and social
status.
Not all may occur, still they pave the way to a process of
marginalization resulting in final exclusion. Mental
illness, if particularly severe and combined with social and
economic uncertainty or outright poverty, is either the
cause or an additional factor leading to marginalization.
The poor mentally ill can be regarded as those
in greatest need amongst the “handicapped”, for
their situation is a veritable psycho-social “handicap”
preventing them from benefiting from the same rights as
other citizens. Their state of neglect and exclusion is
frequently doomed to worsening.
Several complex factors of a structural and personal nature
accelerate exclusion processes in present-day European
societies.
They can be listed as follows:
The
family dissolution, long-term unemployment,
“new” poverty added to the previous state of
need, housing crisis, loss of primaryand
secondary social links, etc.
Health system factors: the disastrous
consequences; resulting from reforms in
mental health legislation which do not
create intermediate and alternative
infrastructures following a decrease in the
number of psychiatric wards or the closing
down of mental hospital
.
Furthermore, the streamlining cuts in health
expenditure are generally followed by
greater administrative obstacles preventing
the least favoured from getting care.
The “discomfort” and “world weariness” experienced
in a society where preference is given on the basis
of competitiveness and productivity, thus causing
failures, stress, emotional shocks, addiction to
“substances”, mental problems, psychiatric diseases,
etc.
People receiving social assistance, individuals
without a permanent lodging, rough sleepers,
«tramps» and vagrants are not “new psychiatric
categories”. Utmost caution is needed to avoid
offering a pretext to those who, all too easily,
claim that “poverty/homelessness equals mental
illness”.
-
Mental weakness, mental illness,
and a
condition of poverty or social uncertainty do interact, and
in the long run they may slide into a permanent state of
extreme degradation.
Individuals who previously suffered from
psychiatric problems and had to put up (for
there never is a deliberate “choice”) with a
“facile, passive, calculated” discharge from an
institution risk becoming rough sleepers or
«tramps» because they fail to get alternative
follow-up treatment.
Individuals with poor or no accommodation very
often begin to suffer or suffer more acutely
from mental disorders and psychiatric diseases
(depression, suicidal behaviour, alcoholism,
addiction to substances, etc.).
Poverty and disease become strictly intertwined in a vicious
circle of marginalization leading to a total loss of social
links.
Experience shows that adequate housing, and appropriate
regular care enable those who suffered or are still
chronically suffering from psychiatric disorders to lead an
independent and satisfactorily autonomous life.
3. European
problem European response
|
In the European Union these people live in
a state of uncertainty for their immediate future. Their
“world weariness” deepens because of the economic crisis and
especially because of the crisis in values: the respect of
an individual’s dignity (who cannot be seen as a mere means
of production), the recognition of diversity, and the value
of solidarity in a society ruled by competitiveness and
productivity for the unproductive and uncompetitive. Thus,
sliding from a situation of marginalization (still
“within” society, even if on its fringes) intoexclusion (“outside”
society) is merely a matter of time.
Marginalization and exclusion affect an increasing number of
people in different areas. Anxiety for the future even
spreads among those who have not yet been affected by
unemployment or poverty.
The extreme situation of the mentally
ill homeless people living
in subway or train stations or on the street is a common
feature of large European cities. It is intolerable because
of:
-
the scale of the problem, even though
precise figures are not available;
-
the serious state of degradation and
exclusion experienced;
-
the high degree of physical and mental
suffering despite apparent “apathy and
aloofness” which might give the
opposite impression.
If persisting for some time and coinciding with physical and
mental stress, the social and economic uncertainty of long
term unemployed or socially assisted individuals, of those
without a permanent lodging or with poor or no
accommodation, of vagrants and «tramps» can reinforce and
accelerate the process of de-socialisation and
marginalization resulting in irreversible “vagrancy” and
social exclusion.
Indifference towards someone else's suffering may result
from being used to outrageous sights, and from a feeling of
helplessness when faced with such complex problems.
This is a European problem which is becoming more serious
every day.
Beyond national differences, this is a European problem: the
problem of marginalization and exclusion is becoming more
and more serious in Europe, hence the need for European
responses.
4. The
need for integrated multidimensional programmes
|
The state of exclusion and
neglect of some people among the mentally ill is certainly
not a priority for policy makers in the social or health
sectors. Sometimes they are not even a priority for the
social or health staff. People suffering from extreme
precariousness do not have the possibility of making
themselves heard to denounce this blatant
non respect of fundamental human rights, social misery and
lack of medical care which
is not their fault or choice.
What does being a man or a woman mean to these mentally ill
homeless people ?
Piecemeal action in favour of this group is a stopgap in
extreme cases of need, when aid is urgently needed, but in
the long run it is ineffective unless supported by political
action allocating resources or active participation of
users. Overall responses to the needs of an individual call
for medium/long term programmes which are:
-
specific and consistent vis-à-vis
the right of each and everyone of us to
physical, mental and social health/well-being,
particularly for the most vulnerable in
society;
-
linked and complementary with
health/social, public/private aspects of policy
makers and staff;
-
integrated and with a community nature so
that they refer to their territory (sector) to
achieve rehabilitation within society and within
families through a type of solidarity that
recognises diversity as well as the autonomy of
individuals.
There cannot be a sectionalised approach to fight
marginalization and exclusion: marginalization results from
various complex and interlocked factors, and experience has
shown that overall, integrated responses are urgently
needed. These responses cannot be offered by “charity”
associations. Public/private organisations working in the
health and social sectors must definitely be involved.
Despite these self-evident truths, initiatives, both at the
national and European levels, tend to adopt a piecemeal
approach deprived of any context. Problems are tackled in
isolation (e.g. physical or mental handicaps, addiction to
drugs or alcohol, unemployment, housing, etc.) ignoring the
links and the complexity of all the factors behind them.
Their solution, however, precisely requires
multidisciplinary, integrated programmes.
5. Interaction
Complementary
Partnership
|
The missing interrelationship and
complementary between social and health policies are best
seen through the many inconsistencies in everyday social and
health practice, which reflects the missing link between
European, national and regional policies. For instance:
-
Social services point out: “the
mentally ill are not our responsibility”
-
Health services react stating: “these are
genuine social cases well outside our remit”
-
Rehabilitation services remark: “they are
unfit for work and we cannot help them”
-
Housing agencies observe: “they do not have
the means to get an accommodation, let alone
keep it”.
Local authorities often wash their hands of these people,
placing a heavy burden on charity organisations and
associations who have toassist those in greatest
need. Various agencies act with charity associations and
volunteers to respond to urgent needs. Constant financial
uncertainty, due to the difficulties in getting grants and
subsidies, prevents medium/long term programmes,
differentiated strategies, innovative initiatives, training
courses, etc.
These services can be viewed as humanitarian
assistance.
They respond to urgent
needs, do
not fitting into social or health programmes with
integrated projects caring for the overall needs of an
individual in a specific environment. The risk is that of
making these people totally dependent on charity assistance.
It goes without saying that the specific initiatives of
private organisations offering solidarity are totally
inadequate without the
involvement of policy makers.
6.
Research
– Action forward studies
|
There are no fixed criteria or statistical
data to assess the number of marginalised and excluded
people. Experience, though, shows that their numbers are
larger than their presence in the street or in subway
stations might lead us one believe to think. Furthermore,
the scale of the problem is bound to increase as immigrants,
especially from Eastern Europe, will come to our society
searching for “well-being”.
In the absence of prevention programmes and consistent
planning, the number of marginalised and excluded mentally
ill homeless people is bound to increase.
Consistent planning to avoid long term ineffectiveness of
fragmented assistance needs a comprehensive,
multidisciplinary study on the problem’s scale and on the
factors behind the exclusion process.
Such a study would overcome the present stage of a policy
based on need, which
risks perpetuating a state of dependence on assistance by
responding to urgent necessities.
In order to achieve these goals, i.e. drawing up specific
programmes with clear targets and creating a network of
integrated structures and services, the study should
analyse:
-
the scale and nature of the problem,
-
social factors and mechanisms leading to
marginalization and exclusion,
-
existing needs and responses in order to
identify missing services.
Urgent problems should never avert attention
from basic ones.
The first priority consists in establishing basic conditions
for a decent life safeguarding the dignity and the
fundamental rights of a person.
A specific medium/long term programme will promote:
A comprehensive study with preliminary multidisciplinary
research.
Before drawing up a programme, a study has to be carried out
on causes, needs of individuals, services provided and those
needed.
Prevention measures which avoid risk groups and individuals,
made more vulnerable by the economic crisis (e.g.
un-integrated youths, women facing family difficulties, the
elderly suffering from isolation, "new" immigrants, etc.),
from slipping towards a state of chronic vagrancy which is
more difficult to overcome at a later stage.
Time combined
with a failure in regular and appropriate continuous
treatment and social assistance are
crucial factors for a temporary condition to become chronic.
The
creation of a network linking integrated and complementary
bodies and service centres (i.e. communities, medical and
rehabilitation services, psychiatric wards in hospitals)
adapting them to needs. More specifically :
-
on the street: (namely in subway and train
stations or on the pavement) this is the first
and most difficult approach which has to be
carried out by specialised staff who know how to
"listen" and establish confidence;
-
in first aid centres which are open 24 hours a
day to respond to crisis situations;
-
in “intermediate structures”: those centres
between “indoors” and “outdoors”, e.g. shelters
and care or treatment centres;
-
in "life spaces" adapted to the needs of
individuals that are to be rehabilitated in
society.
Rehabilitation and work: in these “life spaces” different
job opportunities have to be offered and supported by
observation, guidance, and training structures facilitating
social rehabilitation.
Many previous operative programmes supported innovative
actions and model initiatives intended to "improve the
access to work and the competitiveness of the handicapped
[...] by means of vocational training and [...] economic and
social integration".
The logic here seems to be the same as the one that is the
basis of the job market, namely:
TraininG - Competitivenes
- Production
|
This “strategy” cannot be applied to people suffering from
mental disorders, it does not take into account the
situation of degradation they experience.
Social integration cannot be achieved without a job. A job,
however, does not guarantee automatic rehabilitation. It is
not for the individual to adjust to a job, but for a job to
be the expression of an individual's "participation" and
"production" within society.
An individual may be said to live in a social context as
long as he/she produces services through her/his personal
abilities by participating in the social development of a
community.
The mentally ill have long been condemned to a passive role
leading to the inevitable loss of human potential and at
high social costs.
If only new opportunities could be offered !
The
shocking scenes of mentally ill homeless people on the
streets or in the subway and train stations of large cities
are not merely a reminder of their own status as people on
the fringes of society, but they are also an
indication of the situation in the centre of society, where
the medical and social challenges lie, that is:
Treatment is
not a synonym for cure and
impoverishment/de socialisation lead to world
weariness causing
or worsening diseases.. Alternative and innovative social
and health initiatives have to be devised on the basis of
new theories, which refer to the individual as a whole.
De stabilisation and severance of social links result in the
individual leaving primary and secondary places of
socialisation because of
unemployment and homelessness.
New social rehabilitation and solidarity policies have to be
implemented.
The loss of social identity and citizenship is worsened by
various administrative obstacles which marginalise and
exclude individuals who are deprived of their civil rights
and social status.
Services have to be conceived in order to promote a new
approach to citizenship.
Marginalised individuals do not merely expect a response in
terms of their basic needs (housing, food and clothing),
they are entitled to an overall response that requires:
-
drawing up new strategies in the fight against
marginalization (unemployment, mental illness,
housing, poverty, etc.) within society,
-
promoting a new approach to solidarity,
-
moving from tolerance/acceptance of diversity to
recognition/integration,
-
reaffirming the inalienable rights to health
treatment, social security and housing for all
individuals regardless of their social status.
An overall response will be possible only if there is a change
in attitude
with new values guiding theory and practice. For instance:
staff and volunteers must go beyond the principles of “cure
- treatment” and “reintegration”, policy makers must go
beyond "immediate economic considerations" thus rising to
the new challenge and facing their responsibilities,
vis-à-vis those who have long been on
the fringes
of social and health policies.