Case descriptions

CASE 1

Mr X, a 40-year-old male, lived for a long time in a public park in the city. He habitually arrived at 6:00 pm, laid down on the bench and covered himself entirely from head to toe with his jacket. His clothes were dirty and frayed. His hair and beard were unkempt and a foul odour emanated from beneath his oversized old jacket. He waved away all attempts to hold a conversation with him with a motion indicating “go away”. When asked specific questions, he said he wanted absolutely nothing but to be left alone.

He would not give his name or the name of any relative. In repeated attempts at conversation with him or other “neighbours” in the park, it was impossible to glean any information, except for the fact that he arrived in the evening and remained in the park the entire night, did not speak with anybody and left early in the morning. No one had any idea where he went during the day or how he subsisted. Since there was no name or identity number, we were unable to locate any family or information about his past.

CASE 2

Mr Y rides his bicycle around the metropolitan area all day and all night. His filthy clothes, dishevelled hair and long beard distinguish him from an ordinary cyclist. He appears estranged and detached from society. His bicycle carry-baskets are brimming over with old, apparently useless, objects such as pots, cartons and many bags. The bike was often left standing at the side of the road; it seeemed likely that he had gone to sleep among the roadside bushes.

It was impossible to establish a relationship with Mr Y. When a car stopped or passed nearby, he immediately got on his bicycle and continued on his way. He seemed to be on a long, endless journey, day and night, regardless of rain or summer's heat.

CASE 3

Mr Z was brought to a psychiatric emergency room by the police after he had spent many hours in the park during a rainy, cold night. He refused to undergo any social intervention or identify himself. After observing him for a long period of time, the police became concerned. They brought him in on a particularly cold night. In the emergency room, he refused to identify himself or cooperate. After many hours, a veteran staff member remembered that he had been previously hospitalised in the same hospital due to mental illness.

Discussion

The people described here exemplify the dilemma between, on the one hand, the will and obligation to help the needy, ill person and on the other, the need to respect his wishes to live his life without intervention by external agencies. A conflict exists between respecting the person's autonomy and free will and the “good” paternalism of the therapist who takes care of, and makes decisions for, the mentally ill person who is incapable of knowing what is best for himself.

Patients who are severely ill and a danger to themselves, should be forcefully treated, but there are others who should be treated differently. Of course, the majority of patients would agree to treatment when offered appropriately and at the right time, but the professional staff occasionally finds this restricting, legal approach insufficient. It is very crucial to relate to the person's wishes and to honour them, regardless of that person's illness. But to speak about the free will of certain patients who are severely mentally ill, is incomprehensible. In such cases, lack of involuntary interventions may be a form of collusion with the patient's psychosis.

The first two individuals described could not be helped since they rejected help and no identifying information was attainable. The third man received involuntary psychiatric treatment only after the police intervened and identified him as being possibly dangerous to himself. The experience of former hospitalisation, if traumatic memories remained, might explain his refusal to return to the hospital.

These individuals chose to live in or near the community but were estranged from it. They did not demand anything from the community but whether or not they were needy could not be determined. The law authorises an involuntary psychiatric examination when there is fear that the person might be a danger to himself but the district psychiatrist (who has the power, in Israel, for forced psychiatric investigation) will not send his staff to bring an unknown person in for examination. (Psychiatric staff will not be sent to bring in the “man on the third park bench”.)

In Mr Y's case, even his whereabouts were unknown from night to night. The police may detain a person who has committed a crime, regardless of his refusal to identify himself, but these people behave lawfully.

The question then arises whether this is a social or mental health problem. Is this social deviance, socially accepted self expression or an emotional pathology expressing itself in such a deviance? If someone chooses to be “anonymous” shouldn't we respect his decision? What if behind his anonymity hides his illness?

Whether someone would freely choose to become homeless, living off scraps of garbage and exposed to extreme weather conditions is debatable, but if the mentally ill person is “burnt out” and cannot take care of himself, should we not provide him with help, even against his own will, until his strength and mental health are restored? The patient's rights and his needs should be weighed against each other.¹¹

Sometimes, our multidisciplinary staff feel that words and phrases such as “autonomy” and “free will” are far from the reality we see on the streets. The case of Mrs B, a homeless woman who was brought in for psychiatric treatment, with no diagnosis, no knowledge of her mental capacity, is exemplary.¹² It is interesting to note that she did not identify herself immediately, but provided a false name, similar to our case of Mr Z. The treatment of the homeless mentally ill is more difficult when there are chemical abuse problems,¹³ criminal activity¹⁴ and medication non-compliance.¹⁵

There is a need for a change in the psychiatric services for this population. They should be more diverse and open in approaching this isolated group,¹⁶ with outreach projects such as a street-level approach.¹⁷ Sometimes there is a need for non-governmental agencies, which are trusted more easily by the homeless. Organising a group of citizen volunteers or a self-help group, perhaps including former homeless persons, might encourage the homeless to participate.

Our cases illustrate that where there is an intractable problem of anonymity, talk of unabridged rights excusing obligation is practically nonsensical. We suggest that in questionable cases, when all other efforts have been made and the patient continues living on the street, a multidisciplinary team be given the authority to bring the patient to a general hospital emergency room where his physical, mental health and social needs can be evaluated.

Psychiatric examination, hospitalisation and drug treatment are not the only solutions. The mentally ill homeless can be given clothes, blankets, food or money, thereby facilitating a therapeutic relationship. Discussion of possibilities to provide the homeless with a home, supportive treatment¹⁸ or a therapeutic family¹⁹ may be undertaken after preliminary examination and clarification.

A contradiction exists between these philosophical questions and the feeling of the therapist that action must be taken. We do not feel at ease in discussing this matter in our warm academic rooms while the homeless remain in the cold streets. If society will change and modify the law and regulations, fewer homeless people will suffer or die in the cold.