Days later, when psychiatrist Dr Larina Chi-lap Yim visited the elderly man with the social worker, they discovered that the man was unable to walk, his body trembling with symptoms of urinary and faecal incontinence. They called an ambulance immediately. Yim then revealed her identity as a doctor and wrote a brief health report for the patient to be admitted immediately for psychiatric treatment. According to Yim, this is an example of how homeless individuals with mental illnesses are commonly identified for medical attention through her outreach efforts.
In this exclusive interview, Yim shares her stories on how she works hand-in-hand with social workers and NGO to identify the neglected population in the city – and the challenges in treating mental illness among homeless individuals in Hong Kong.
70% of homeless individuals have a lifetime history of mental illnessAccording to the Homeless Outreach Population Estimation study (HOPE Hong Kong 2015) conducted by researchers at the City University of Hong Kong (CityU) and their collaborators, 1,614 individuals sleep on the streets in the seemingly affluent city of Hong Kong. Although the number was considered significant and expected to grow, not much attention was paid to the health – let alone mental health – of these individuals.
In view of this, Yim collaborated with The Salvation Army, St. James’ Settlement and The Christian Concern for the Homeless Association in 2011 to conduct a study. With the help from social workers, Yim travelled to every corner in the city and conducted interviews with the homeless individuals in person, aiming to determine the prevalence of mental illness in the homeless population in Hong Kong while exploring their barriers to accessing mental health services.
The study lasted till June 2012 and was published in October 2015. Results revealed that more than 70% of homeless individuals who participated in the study had a lifetime history of mental illness. In stark contrast, only 13% of those with mental illness were receiving psychiatric care at the time of the interview. More disturbingly, the prevalence of mental illness in the study population was already hugely underestimated since a significant proportion (18%) of the subjects initially selected were too ill to give consent to participate in the study.
We have seen sleepers with dementia who wrapped themselves with only plastic bags in winter, and wore thick clothes during summer. We have also seen a sleeper who was addicted to drugs and was holding his own faeces in his hands. There was another sleeper who covered himself with cardboard boxes. When we tried to remove the boxes to talk to him, we found there was a dead mouse inside,” recalls Yim. “These sleepers have lost the ability to take care of themselves. Some of the situation were even worse,” asserts Yim.
Yim recalls another case when a man with suspected schizophrenia and dementia, who was originally living in hostel, became homeless for around two years. “The first time when we visited him, his legs were swollen and we didn’t make much progress as he was not willing to speak to any of us,” reminisces Yim. It was until the social workers finally managed to find his previous tenant, who had the contacts of the patient’s sister. “She admitted to us that her brother had been refusing to return home for a long time. He would only contact her to borrow money,” she adds.
Yim then explained the patient’s condition to the sister – and asked if the family members are willing to send the patient to the hospital for treatment. With the help of social workers, they finally arranged a meet for the patient and his sister. Subsequently, the social workers grasped the chance to convince the patient to undergo simple check-up, given his health conditions; such as measuring blood pressure. Upon further medical treatment by psychiatrists, the patient’s condition gradually improved. His family has even sent their family photos to the social workers to express their gratitude.
A medical-social collaboration model to support street sleepersSuch case reflected the difficulties and restrictions to keep track and take care of the street sleepers under existing government’s policy and resources. “Social workers working under government’s Integrated Community Centre for Mental Wellness (ICCMW) do not contact hospitals directly when they discover a street sleeper with suspected mental illness. Instead, they conduct a paper review every two to three months to see if it’s necessary to inform hospitals’ community outreach team to initiate an outreach service for visiting the patient. By the time a decision is made, the street sleeper may have already moved to another place,” says Yim.
In 2014, she decided to take a step further and proposed the “Cure Angels” Community Health Service Spots project to The Salvation Army. Together, they set up the city’s first-ever mobile service station, offering physical and mental health examinations, basic medical treatment, escort services for medical consultations and medical referrals for homeless individuals. “Social workers are the backbone of the project. The time I spend or what I contribute consists of a very little part of the project only,” she emphasises.
“They usually refer sleepers with confirmed or suspected mental illness to me. So, every time when we go out, we have certain targets to visit,” explains Yim. “If the sleepers only display mild symptoms, I would reveal my identity as a doctor; and casually ask if they have any discomfort. Then, I would inform the social workers of the signs they should take note of in these patients, and they would let me know if their conditions deteriorate. However, if the patients are severely ill, we would evaluate and see if we should call an ambulance and send them to a hospital after paying them another 1 or 2 visits.”
Yet, the job doesn’t end here.
“Things are better if the patients are accompanied by a social worker when they are admitted. The social worker would contact doctors and nurses in the hospital, ensuring the patients are followed up by psychiatrists. When the patients are ready to be discharged, the hospital would contact the social worker since most homeless individuals have lost contact with their friends or family members,” Yim shares.
“Sometimes, patients who display psychotic symptoms in public areas are sent to hospitals without the accompany of social workers. In this case, the hospital may not know there is a social worker who has been taking care of the patient. When the patient refuses to stay in the hospital, it may discharge the patient, who does not know how to take care of himself/herself, without informing the social worker,” says Yim. “It would be much more difficult to convince the patient to go back to hospitals for treatment after that. Ultimately, the patient’s mental illness may worsen. Sooner or later, he/she will be admitted to the hospital again with poorer conditions.”
Hong Kong in need of psychologists, psychiatric nurses, social workers and cheaper landIn recent years, tragedies involving patients with severe mental illness have often stirred up heated debates on whether it is appropriate and practical to introduce Community Treatment Order (CTO) as a legal instrument to compel patients with mental illness to receive psychiatric treatment in the community.
Yim further reiterates that the key to improving patient’s clinical outcomes lies in the “relationship between the patient and his/her caretaker”. “We can for sure make use of CTO to force the patient to take medications. But, what if the patient refuse to do so? Does that mean we need to send healthcare professionals to the patient every day to force him/her to take the medication?” questions Yim. “If I was the patient and I foresee that you would force me to undergo treatment and take medications with CTO – I would simply choose not to see a doctor.”
Yim comments that it takes time to establish a relationship with the patients. And, it is dangerous to enforce CTO without sufficient healthcare professionals. “Apart from medications, counselling therapies are also very important to patients. But, we don’t have enough psychologists in the hospitals,” says Yim.
Currently, the Hospital Authority (HA) has approximately 90 psychologists working in the psychiatric stream in the HA. Due to the insufficient number, patients can only meet the psychologist once every few months, rendering the therapies ineffective.
Psychiatric nurses are also in short of manpower. “By reducing the nurse-to-patient ratio, they can increase the frequency to visiting patients in the community,” says Yim.
Besides psychologists and psychiatric nurses, Yim points out that the city is in need of social workers. “The prevalence of mental illness among homeless people is high – but many are not aware of the need to seek help. Indeed, not just the homeless, but also the elderly living alone at home. We need more social workers to reach out to these neglected population, and offer them a helping hand,” she laments.
As our chat comes to a wrap, Yim simply shares her observation: a trend whereby the street sleepers are getting younger. “If I live alone, why would I need to rent a subdivided flat at such exorbitant price? Why not just sleep in 24-hour fast food shops or the airport?” she asks. MIMS
(Editor’s note: This article has been updated on 8 February, 2018)
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