"All people have the right to the best available

mental health care, which shall be part

of the health and social care system".

                                                                                                                      (Resolution 46/119,1.1, Gen. Ass. UN, 17/12/1991)

            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 nine 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”, 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 centre might 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.

                Marginalizing and exclusion processes are rarely deliberately “chosen”, they are sometimes merely endured, and all too often imposed 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: 

q              Socio-economic and cultural factors:

The family dissolution, long-term unemployment, “new” poverty added to the previous state of need, housing crisis, loss of primary and secondary social links, etc. 

q              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 hospitals.

Furthermore, the streamlining cuts in health expenditure are generally followed by greater administrative obstacles preventing the least favoured from getting care. 

q              Psychological and emotional factors:

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.  

                  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) into exclusion (“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. 

                              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.

               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 to assist 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.

               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: 

.

 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.

Luigi LEONORI