I MET PAT when he was at his lowest ebb and had been on the streets for three days.
Pat had serious mental health problems. He was hearing voices and was also using drugs to try to kill the pain.
He had sat for hours in the Accident & Emergency department but unlike most other people there that day, he never received treatment.
The A&E staff did not assess him or admit him instead they referred him to an addiction service in Dublin city centre.
But when Pat attended that addiction service he told them that he intended to take his own life if the voices didn’t stop. So they sent him to psychiatric services.
The addiction service refused to work with him until his psychiatric illness was dealt with and the mental health services refused him because he was using substances.
Every door was closed on Pat. He was scared and exhausted, having left his house days earlier and was refusing to go back. He was convinced that there were people ‘after him’ and that when they caught him they would go after his family too.
He explained to me that he went to the hospital because he was frightened and his family had insisted it was time for him to get help.
Pat was having a definite psychiatric episode but shamefully because he was also a substance user, our psychiatric services refused to treat him.
A short time later I heard that Pat had overdosed in homeless accommodation and died.
Pat’s case might sound like an extreme one but anyone who works in homeless services will tell you that this issue is actually very common.
There are many, many sad and shameful cases of people being turned away from accessing health services because some of their issues are deemed to be non-medical.
When a person presents with psychiatric and addiction issues in Ireland they are routinely sent away and referred to addiction services – who in turn just send them straight back to the hospital.
What is going on is a fairly baffling attempt to separate addiction from mental health. It is as if the person taking the substance is separate from the person experiencing the mental illness, when in fact they are one person and the two issues are obviously interrelated.
Addiction is not a moral weakness but is itself a mental illness and it is listed as such in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association which is basically the psychiatrist’s bible.
When a person has both mental health and substance use issues, health professionals call this dual diagnosis. There are very few services here that work with people with dual diagnosis.
What always stands out to me is that the distinction between these two problem types is immensely arbitrary.
The underlying causal factors are the same – they are social issues, family breakdowns, poverty and especially trauma. It is fair to say that while there will be some difference in service provision they also have significant overlap.
Often the reason cited for discharge from mental health services is the addiction and vice versa – services blame the ‘other’ diagnosis for the person being discharged, without fully accepting that maybe they could and should have done more.
When someone takes their own life, people say:
Why didn’t they just ask for help? If only they had things could have been different.
Sadly, many people like Pat, do seek help and they are being turned away from mental health services.
Recently in a conversation with a clinical psychologist, he suggested that there is massive pressure on those who provide services. Not only are they under-resourced, but they are also trained to believe that their service cannot help or isn’t suitable for certain people.
A radical change of approach in supporting people with a dual diagnosis is now long overdue. We must resource and train all service providers to be able to respond to people in a holistic way.
My hope for 2019 is that our health service implements the ‘no wrong door ‘ recommendation of the Cross Party Committee on Mental Health.
That would mean that never again, would someone like Pat, be turned away from mental health services – or be told that they have knocked on the wrong door.