Which leads to some schizophrenics becoming homeless

Supervisor of mentally ill homeless people: "Spit out by the system"

Street social worker Julien Thiele and psychiatrist Richard Becker seek out homeless people with mental health problems. The need for action is underestimated.

Very neglected and difficult to address: the support often leans back Photo: dpa

taz: Mr. Becker, Mr. Thiele, does almost every homeless person carry a mental illness with them?

Richard Becker: Now I'm going to be spiteful: Define mental illness.

Everything from addictions to psychotic disorders to depression and messie syndrome.

Julien Thiele: With your question you are referring to the largest German study to date on the connection between homelessness and mental illness, the Sea Wolf Study, right? It met with a lot of criticism precisely with this basic assumption.

That's why I'm passing the question on to you, because you work as a street social worker and psychiatrist with this group of people. Or is it not allowed to approach it like that?

Becker: Yes, yes. Julien and I have been doing two hours of street work on Wednesdays for over a year with the Caritas project “Citymobil”. And we are in the practice two hours a week and offer a free psychiatric consultation. During this time I have not met a person whom I would not call a patient. The question immediately arises: are we talking about mental disorders or unprocessed traumatizations? And: which came first, the hen or the egg?

67, a psychiatrist, dropped out of school in England and worked as a monkey keeper at the London Zoo. In Germany he made up his Abitur and was a geriatric nurse. After studying psychology, he worked with seriously ill patients, including in the Hamburg-Ochsenzoll psychiatry. Now he takes care of the mentally ill homeless on the street.

And? Hen or egg?

Becker: We would sit here forever without coming to a conclusion. But, in my opinion, everyone who lives on the street and in whose lives we have some, albeit discreet, insight into their lives has a need for psychiatric or psychological support. However, I cannot allow myself to judge all the people from Syria, Afghanistan and so on because there is no common language.

27, comes from the Osterzgebirge, learned to cook in Dresden and worked as a cook in Hamburg. He studied social work and is a street social worker in a single house for men and in the Caritas “Citymobil” project.

Thiele: At the time when migration was not so strong, it could be assumed that the German homeless were suffering from a mental disorder. As a social worker, however, I am initially fighting not to make this illness the main object of help for people with mental illness.

How do you get to people to offer them help?

Thiele: I am regularly on the road and already have people on my radar. Whenever I'm out with Richard, I make a targeted effort to find the right people who I think have a problem that Richard could help with.

And who are you specifically looking for?

Thiele: Be it a woman who always rejects everyone, or a person who pushes many trolleys a little further all day, or someone who accumulates a lot of bags. And then we try to get in touch. Many of them are afraid of the institutions, including the medical help system, and turn us away for the time being. Because sometimes the mental illness was also the trigger for homelessness.

What happens in such cases?

Thiele: We experience that people go to psychological or psychiatric treatment, are perhaps forcibly admitted, and during this time lose everything else because nobody cares anymore, for example relatives or social services in the treatment centers. We usually talk about already lonely people.

Becker: So people usually know that if they behave in one way or another, they'll end up in a nutcase, and if they're very unlucky in Hamburg, they'll come to Ochsenzoll. The willingness to seek help is therefore very low. Julien and I have therefore agreed to say that I am a doctor. Which is not a lie, I am a doctor. When the conversation reveals that I am a psychiatrist and also worked in Ochsenzoll, sometimes the shit is on the steam. Nobody wants to be labeled crazy. That's why I started telling people: “You have an emotional and a social problem. Mr. Thiele is responsible for the social and I for the emotional, for the conversations. ”This is how we get to know people very well.

Thiele: The combination of psychiatrist and social worker who visit people on the street together works well. We can build trust better and also recognize where the problem of the individual person lies and how we can perhaps help. In this way we may also manage to counteract the psychiatrist with a new type of initial contact, and then people will dare to accept this help.

Becker: But with the few hours I have there, it's hard to really get behind what's going on with someone who is conspicuous. If you cannot come into contact with a person, any suspected diagnosis is presumptuous. It would be more than desirable if psychiatrists, who are connected to a clinic, would take to the streets with us and had a reasonable number of hours, because we are only financed by donations.

Why are there no funds for this?

Thiele: There is actually an awareness of this problem in Hamburg. There are plans in the current coalition agreement that focus on mentally ill people and target explicitly adapted offers. In my opinion, nothing has been planned or implemented so far. It is always pointed out that there is already a good help system in place. But the mental illness is precisely the hurdle to accept this help.

Becker: There is no coordinated system in Hamburg for tackling homelessness. It's piece work. It starts with doctors in the hospitals assessing the admitted people, including the homeless with a mental disorder. Then there are judges who have an idea of ​​a career ahead of them, but first have to go through the deep valley of homelessness, and then there are legal guardians who earn their living caring for a chronically mentally ill person. Their pay has been reduced quite a bit and that's why a lot of very dedicated people have disappeared. There is little contact between the systems and little direct coordination with each other and with those affected.

Thiele: And all of them work with very high case numbers.

Becker: Exactly. Then there are the socio-educational institutions that look after these people and at the very end of the chain there are people like Julien who visit people on the street. We lose the mentally ill homeless, they are simply spat out by the system, including the medical system. Let me give you an example: We met Ms. S. How long have you been behind the court and the support in her case?

Thiele: Probably half a year.

Becker: If a social worker would get support from the court, for example, and could hang in there and not have to deal with countless other cases, then this story could have been solved in two months.

What is the story of Mrs. S.?

Thiele: This is a woman over 80 who comes from Switzerland, has dementia and she is psychotic, schizophrenic somehow. Of course, she had no entitlements here and, for example, could not use the winter emergency program at all because she had to leave it during the day, and after an hour she no longer knew where she had slept last night, let alone how to get there . And then we recorded them.

How did the contact come about?

Thiele: By chance, we met her at the main train station.

Becker: One of our best employees is chance.

Thiele: When we are on the road, we address people who are obviously homeless and can of course only follow stereotypes. But our Citymobil project is designed precisely for this group of people who are very conspicuous, very neglected and difficult to address and who do not even use the help system. And just like people, we also fail when faced with hurdles. Because here the supervisor often leans back and says: “We can't do more than you are doing anyway.” As soon as the legal supervision is in place, we no longer have it in our hands and can only ask how far the help is. Our offer of support is rarely accepted. And with Ms. S. it was the classic case: nothing at all happened.

And then?

Thiele: We then found out that the legal guardian had settled her costs and the care had been discontinued.

With what justification?

Thiele: That Ms. S. has no claim here, Switzerland is also not in the EU and so on, you didn't feel responsible and you were simply overwhelmed. I was really scared of the law. The lady just couldn't take care of herself.

And then?

Thiele: We have a container project here for homeless women and that's where we put them. We have expanded our range especially for her, made extra meals here in the mornings and evenings, I motivated her to shower, washed her laundry, cleaned her container, tried to take her to the doctor, and even brought the doctor to her and tried to develop a perspective for her. And then the court announced: “You don't even know if you can take care of yourself after all, wait two weeks and reduce your offer.” But we've already seen how big they are There was a need and that she cannot do it alone. Then we heard nothing more from the court. We accompanied her back to her home country, Switzerland, and she still lives there today.

Is that a classic case?

Thiele: Yes. Be it due to the high number of cases or be it just overwhelmed with the situation. When we apply for a legal guardian, we make the urgency clear and then often notice that our cases are apparently going to the bottom of the pile, because the people in charge also know that there is not much that can be done here.

Isn't that also true somehow?

Thiele: Yes, a legal guardian can actually do little alone, but in combination with a social worker who visits people on the street, a lot is possible. In order to reach the mentally ill homeless, we have to get out of the institutions and go to the people.

Becker: When I started the project here, I looked through the roughly 2,000 patients in the main practices on the computer, the diagnoses were also noted there, and it was predominantly alcoholism. Psychiatric illnesses in the strict sense not even a handful.

What kind of diagnoses were those?

Becker: Schizophrenia, personality disorder, depression. I then made it my business to write down a suspected diagnosis that had at least a little substance. We hardly find anyone on the street who has not just had a beer. So you can subjugate all alcoholism. Hamburg would do well to have a psychiatrist with a connection to a clinic who spends at least 50 percent of his working hours on the street and knows the social workers on the street and thus at some point also knows the mentally ill homeless and has an idea of ​​the living situation. That is the minimum requirement.

Thiele: We also experience in our other medical aid projects that one cannot work without the other. Many of those affected know for themselves how difficult it is to get back into living space, even without a mental disorder. They have often had the experience that there is nothing for them, perhaps they have already been kicked out of institutions because they cannot adapt. The people are complicated for the rule system and overwhelm everyone, the clinics, but also the facilities for homeless people, are partially banned from entering. In Hamburg, for example, there are hardly any single rooms for men in emergency accommodation, there are hardly any contact points, and psychiatric consultation hours have broken down in almost all facilities.

Bremen is now redesigning refugee accommodation in 28 single rooms for the mentally ill homeless. Is this a good idea?

Thiele: Yes, you just have to manage that people don't influence each other negatively. We are experiencing that with our container project for women, it's totally low-threshold, you don't have to meet any conditions, if you need a single room, you get one and then it's good. We experience that people can accept that. However, it is small and must be understood as a coercive community.

Why was care for the mentally ill in Hamburg reduced? The need hasn't gotten smaller, has it?

Thiele: There was a project between the city and the University of Hamburg and it has been found that it is very good to treat people who do not come within the standard system. There are three main practices for this, one of which is run by Caritas, but psychiatric consultation hours are difficult to fill and therefore rarely exist. It is also difficult to find psychiatrists who deal with this group of people. On the other hand, there is lively interest among the other medical professionals who, for example, drive out in the ambulance.

How so?

Thiele: I believe because the help is more tangible. You put this plaster on. You give this tablet with you. And then there is a larger system in which a better help process can take place.

Has the problem of mental illness been properly grasped at all?

Thiele: All sides know that this problem exists. It is also visible from afar in the Hamburg cityscape. And it stays that way: you just have to get out on the street, to where the people are, and create spaces as a basis that allow entry almost unconditionally and allow room for maneuver. If you ask a homeless person where they can get medical help, most of them can tell you exactly what consultation hours are, when, where the ambulance is, and so on. But if I asked those affected, "Do you know where to go if you ever want to talk to someone or have a mental problem", most of them would say: "No."