Re-thinking homelessness and mental health policy

The ‘tent city’ blighting Martin Place outside the Reserve Bank of Australia raises important questions about the cause of homelessness.

Predictably, Sydney City Council justifies its appalling inaction by arguing the state government is failing to provide affordable housing and support to the homeless. In response, the NSW Government has rightly pointed out that the state spends over $1 billion a year on homelessness and social housing services, and therefore no one needs to live in a tent in the middle of Sydney.

But, when you consider that many of those who ‘sleep rough’ are mentally ill, perhaps the bigger issue is the inadequacy of the current approach to the treatment of mental illness.

Given what we know about what went on behind the closed doors of the asylums, the policy of ‘de-institutionalisation’ — which was implemented in NSW in 1980s — appears to be well justified.

Yet the correlation between mental illness and homelessness suggests that well-intentioned efforts to develop a more humane model of community-based treatment may have unintended side effects.

This ‘model of care’ may simply be fundamentally inappropriate and unable to meet the needs of those with severe mental illness.

Those suffering severe mental illness might end up homeless, in gaol, or in public hospital emergency departments and wards, because it is simply impossible to provide the intensive level of care, support and management they require, in an affordable manner, in the community.

These questions about the direction of mental health policy over the last 40 years are openly discussed in the United States.

However, in Australia the prevailing view among experts and stakeholders seems to be that community care is best, regardless of evidence — such as homelessness — that contradicts this.

Raising this subject also goes against the grain of contemporary mental health policy advocacy, which is focused on disassociating mental illness from the prejudices of the institutional era, and on promoting prevention and treatment of less severe conditions.

All efforts to de-stigmatise mental illness and encourage people to acknowledge their mental health problems and seek help and support should be applauded.

But if we want to address the problem of chronic homelessness, we may need to broaden the mental health debate, and focus on the more difficult issues associated with re-thinking the community-based model of treatment.

This is adapted from a speech Dr Jeremy Sammut gave at The Economic Society of Australia’s Australian Conference of Economists in Sydney this month.