Staying alive: Mental Health service interventions for people sleeping rough
Peter was well known to the outreach team. He slept in a small bin cupboard on a council estate. When approached by the outreach team he would politely turn down offers of help, saying that he was fine. Little was known about how he spent his time during the day. He would regularly attend a day centre but would stay briefly, eating a few slices of toast, and move on.
Due to his poor self-care and lack of engagement the outreach workers suspected that he may have mental health difficulties, but how can we decide whether Peter is making a lifestyle choice to live on the streets, or that his decision to refuse help to access housing is impaired by mental illness?
Although we should respect people’s decisions to lead their lives as they wish, society accepts that due to mental illness, or other impairments, such as learning disability, people may be unable to make decisions for themselves.
This is supported by legislation, mainly the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA). The MHA provides a legal framework for interventions for people with a defined mental disorder who are assessed as a risk to themselves or others. The MCA has a wider remit, encompassing people with any kind of ‘impairment of the mind or brain’ such as learning disability or intoxication through drugs and alcohol, as well as those with mental illness.
Where a person sleeping rough is refusing offers of help due to a mental illness and exhaustive attempts have been made, progress may only be possible by admission to hospital and treatment under the MHA. Although in such a situation the only option is to admit them under the powers of the MHA, the MCA provides a test of capacity which can be a useful framework to explore whether their decision to refuse help is due to their ‘impairment’, or is merely an ‘unwise decision’. In life, we all make unwise decisions and society does not have a right to stop us.
The MCA test of capacity requires evidence of an impairment. With Peter there had been a past history of psychotic symptoms and his poor self-care was evidence of possible negative symptoms of schizophrenia. His inability to explain his decision to refuse offers of help led to the conclusion that he lacked capacity to make decisions regarding whether or not to accept help with accommodation. A decision was then made that his decision to sleep rough, being driven by his mental illness, was a sufficient risk to his health and safety to warrant admission to hospital for assessment under the MHA.
The MCA can also lead to a decision to leave someone as they are. Steve aggressively resisted help from outreach services (on one occasion chasing workers away from his sleep site) and outreach workers had reason to suspect that he was mentally unwell. An assessment was arranged under the MHA and, as part of this, his capacity to choose to sleep on the streets was tested using the framework of the MCA. Although it was still thought he may be suffering with a mental illness, he demonstrated capacity to make the decision to sleep on the street. It was therefore agreed that any mental health difficulties were not leading to his decision to sleep on the street and the decision was made not to intervene.
Homeless Link's related course will enable participants to assess a person’s capacity to make decisions relating to sleeping rough and explore when the Mental Health Act and other statutory frameworks will be relevant for someone sleeping rough.
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