The Search for Meaning: Eventfulness in the Lives of Homeless Mentally Ill Persons in the Skid Row District of Los Angeles

In the past two decades, the field ofpsychiatry has seen the once dominantpsychoanalytic theories overtaken by biologicalexplanations and approaches to severe mentalillness. With this change in perspective, thesignificance of fantasies and delusions havebeen reduced to being merely symptoms ofpsychopathology rather than reflections ofhuman needs and motivations. Usingethnographic evidence from a long-term researchproject, this paper explores one method bywhich mentally ill homeless individuals in theSkid Row district of Los Angeles attempted towrest meaningful lives for themselves out of anenvironment that featured disaffiliation,violence, boredom, and extreme poverty.     

Estimating numbers of homeless and homeless mentally ill people in north east Westminster by using capture-recapture analysis.

OBJECTIVES--To use routinely collected data to provide a reliable estimate of the size and psychiatric morbidity of the homeless population of a given geographical area by using capture-recapture analysis. DESIGN--A multiple sample, log-linear capture-recapture method was applied to a defined area of central London during 6 months. The method calculates the total homeless population from the sum of the population actually observed and an estimate of the unobserved population. Data were collected from local agencies used by homeless people. SUBJECTS--Homeless people in north east Westminster residing in bed and breakfast accommodation and hotels or sleeping rough who had contacted statutory or voluntary agencies in the area. RESULTS--2150 contacts by 1640 homeless people were recorded. The estimated unobserved population was 3293, giving a total homeless population for the period of around 5000 (SD 1250). Mental health problems were significantly less prominent in the unobserved compared with the observed population (23% (754) v 40% (627), P < 0.0001). For both groups the prevalence varied greatly with age and sex. CONCLUSIONS--Capture-recapture techniques can overcome problems of ascertainment in estimating populations of homeless and homeless mentally ill people. Prevalences of mental illness derived from surveys that do not correct for ascertainment are likely to be falsely inflated while at the same time underestimating the total size of the homeless mentally ill population. Population estimates derived from capture-recapture techniques may usefully provide a good basis for including homeless populations in capitation calculations for allocating funds within health services.     

What happens to homeless mentally ill people? Follow up of residents of Oxford hostels for the homeless.

OBJECTIVES--To follow up severely mentally ill residents of hostels for the homeless to determine their social and psychiatric outcome. DESIGN--Follow up at 18 months of hostel residents previously assessed with psychiatric and behavioural measures. SETTING--Two Oxford hostels for the homeless. SUBJECTS--48 hostel residents previously identified as disabled by mental illness. MAIN OUTCOME MEASURES--Current housing, admissions to psychiatric hospital, violent or antisocial behaviour, and score on standardised behavioural rating. RESULTS--45 of the 48 residents were traced. 27 had remained in the hostels; only 10 had been rehoused, mainly in bedsits or with their families. 16 had a poor outcome as judged by death (four subjects), lengthy hospital readmission (two), marked deterioration in behaviour (six), sleeping rough (one), or disappearance (three). CONCLUSION--More effort is needed to provide suitable housing for homeless mentally ill people.     

Attitudes and sterotypes of supporting fields towards the persons with disabilities

The aim of this research was to establish the attitudes, the views and reactions of the helping fields (which include social workers and medical nurses) and those who aren't the part of that cathegory, towards the mentally ill people. One hundred and twenty persons questioned have taken part in this research where in the group of supporting fields consisted of social workers and medical nurses (N = 40). The questionnaire was used in examining the attitudes of those questioned persons, the questionnaire that was used in Joki?-Begi?'s research (2005) and it turned out to be a really good one in defining the attitudes and stereotypes towards the mentally ill persons. The questionnaire consisted of several parts in which different things have been examined such as stereotypes, knowledge, attitudes, level of acceptance and social- demographic information. The research has shown the differences among the attitudes and the level of acceptance of the mentally ill as well as the level of knowledge which the examinees had. All the examinees that have been the part of this research mentioned "ill" as a dominant trait of the mentally disturbed person. Furthermore, the characteristics such as instability, insecurity, nervousness and inclination to suicide, indicate that all of these three groups of examinees have sterotypes about unstable emotional condition and state of mind of the sick. The examinees that don't belong to this group of supporting fields have enough knowledge neither about the emergence of the disease nor about its development and preventive measures. However, the social workers have a bit more negative attitude towards the mentally ill if compared to medical nurses which could be explained by insufficient working experience with the mentioned group of patients. It's important to say that all of the three groups of examinees don't have extremely negative attitudes towards the people with mental disorder. We shouldn't ignore the fact that these three groups have noticable social restraint towards the mentally ill and they cannot easily accept them in their own environment. Considering the fact there is a low number of researches that deal with this problem of labelling or in other words- stigmatization of the mentally ill, this research gives a great stimulus for writeup this very important problem area, especially if we take into consideration that the attitude of the community may help to bring about the feeling of marginalization and unacceptability with the mentally ill.     

Reaching impaired populations with HIV prevention programs: a clinical trial for homeless mentally ill African-American men.

This study tested an intervention to reduce sexual risk behaviors in a high risk impaired population: homeless African-American, Caucasian and Hispanic men with mental illness. In a comparison group clinical trial, men were assigned to an experimental cognitive-behavioral or a control intervention and followed up over 16 months. Men were recruited from a psychiatric program in two shelters for homeless men in Nashville, Tennessee. An ethnically mixed cohort of subjects (54% African-American, 42% Caucasian and 4% Hispanic) were included in the study. Most had a chronic psychiatric disorder and a co-morbid substance abuse disorder. The 257 participants who were sexually active (130 experimental, 127 control) prior to the trial were the main target of the intervention. An experimental intervention (SexG), adapted from Susser and Associates (51), comprised 6 group sessions. The control intervention was a 6-session HIV educational program. Sexual risk behavior was the primary outcome. The experimental and control groups were compared with respect to the mean score on a sexual risk index. Complete follow-up data were obtained on 257 men (100%) for the initial six-month follow-up. These individuals have been followed for the remainder of the 16-month follow-up. This intervention, (SexG), successfully reduced sexual risk behaviors of homeless mentally ill African-American, Caucasian and Hispanic men. Similar approaches may be effective in other impaired high-risk populations.     

“Because Somebody Cared about Me. That's How It Changed Things”: Homeless,Chronically Ill Patients’ Perspectives on Case Management

Background

Case management programs for chronically ill, homeless people improve health and resource utilization by linking patients with case managers focused on improving management of medical and psychosocial problems. Little is known about participants’ perspectives on case management interventions.

Methods

This qualitative study used in-depth, one-on-one interviews to understand the impact of a case management program from the perspective of participants. A standardized interview guide with open-ended questions explored experiences with the case management program and feelings about readiness to leave the program.

Results

Four recurrent themes emerged: (1) Participants described profound social isolation prior to case management program enrollment; (2) Participants perceived that caring personal relationships with case managers were key to the program; (3) Participants valued assistance with navigating medical and social systems; and (4) Participants perceived that their health improved through both the interpersonal and the practical aspects of case management.

Conclusions

Chronically ill, homeless people enrolled in a case management program perceived that social support from case managers resulted in improved health. Programs for this population should consider explicitly including comprehensive social support interventions. Further research on case management should explore the impact of different types of social support on outcomes for homeless chronically ill patients.     

Community Writing, Participatory Research, and an Anthropological Sensibility

Participatory research is a radical praxis through which marginalized people acquire research capabilities that they use to transform their own lives. In this article, I examine how parent writers incorporated facets of community writing into their research practice as they developed their practices and identities as researchers. I also consider how anthropology, as both research practice and sensibility, contributed to the ways I engaged as an outside collaborator with these parent researchers.  [community writing, participatory research, praxis, anthropological sensibility]     

Prevalence of Mental Illness among Homeless People in Hong Kong

MetholodogyThis study examined the prevalence and correlates of mental illness in homeless people in Hong Kong and explored the barriers preventing their access to health care. Ninety-seven Cantonese-speaking Chinese who were homeless during the study period were selected at random from the records of the three organisations serving the homeless population. The response rate was 69%. Seventeen subjects could not give valid consent due to their poor mental state, so their responses were excluded from the data analysis. A psychiatrist administered the Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I) and the Mini -Mental State Examination. Consensus diagnoses for subjects who could not complete the SCID-I were established by three independent psychiatrists.FindingsThe point prevalence of mental illness was 56%. Seventy-one percent of the subjects had a lifetime history of mental illness, 30% had a mood disorder, 25% had an alcohol use disorder, 25% had a substance use disorder, 10% had a psychotic disorder, 10% had an anxiety disorder and 6% had dementia. Forty-one percent of the subjects with mental illness had undergone a previous psychiatric assessment. Only 13% of the subjects with mental illness were receiving psychiatric care at the time of interview. The prevalence of psychotic disorders, dementia and the rate of under treatment are hugely underestimated, as a significant proportion (18%) of the subjects initially selected were too ill to give consent to join the study.ConclusionThe low treatment rate and the presence of this severely ill and unreached group of homeless people reflect the fact that the current mode of service delivery is failing to support the most severely ill homeless individuals.     

Impact of an integrated service system on client outcomes by gender in a national sample of a mentally ill homeless population

Background: Homeless populations with concurrent mental illness have a complex array of service needs that are often addressed in a haphazard or uncoordinated manner. Information is lacking about the effectiveness of programs and public policy in women who are both homeless and mentally ill.Objective: This study assessed the impact of gender on the outcomes of a multisite public policy intervention that implemented components of an integrated service delivery system to address the needs of mentally ill homeless men and women.Methods: A secondary analysis was performed using longitudinal data obtained from homeless men and women in the Access to Community Care and Effective Services and Supports prospective study, which was conducted at 18 sites across the United States. Outcome data from baseline, 3, 12, and 18 months across 5 annual cohorts were analyzed to determine the impact of gender on 6 clinical outcomes, including days of housing, relationships, victimization, social support, alcohol use, and drug use, in homeless men and women with mental illness. The analysis plan included multilevel modeling of longitudinal data.Results: Data were analyzed from a total of 7229 participants, including 4502 men (62%)) (mean age, 38.2 years) and 2727 women (38%) (mean age, 37.2 years). After 18 months of follow-up, women had significantly better outcomes in terms of family relationships (estimated mean score increased 0.100), victimization (score decreased 0.164), and social support (score increased 0.363) than did men (aall, P < 0.001). Being accompanied by children was significantly associated with less change in drug use among women compared with men (P < 0.01). These outcomes were the same across all 18 program sites.Conclusion: Although the addition of services for the homeless in conjunction with clinical and support services offered by case managers had generally positive effects in this study's population, a gender-specific substance abuse treatment intervention should also be included in a comprehensive program for homeless women with mental illness.     

‘I need help’: caregivers' experiences of caring for their relatives with mental illness in Jamaica

The findings reported here form part of a larger research project that examined non-compliance with medication among the mentally ill patients attending public clinics in a specific parish in Jamaica. The aim of the research was to explore the perceptions of caregivers about caring for the mentally ill at two outpatient psychiatric clinics. Caregivers involved in looking after their relatives with mental illness played a vital role in mental health promotion. This study sought to examine the caregivers'' perception of mental illness, including how they thought the illness was best controlled, the reasons why their relatives found it difficult to take their medication as instructed, and the coping skills that they employed when caring for their relatives. There were two focus groups, consisting of four individuals each, at two psychiatric clinics.The results revealed the following about the majority of the caregivers. First, it was recognised that caregivers have a good knowledge (and awareness) of medication usage inferred by either the absence or the presence of their relatives'' symptoms. Secondly, they sometimes felt sad and hopeless as a result of being the victims of violent attacks by those for whom they provided care. Thirdly, they highlighted issues of cost, accessibility and availability of medications as being problematic. Fourthly, in some cases they received little or no assistance from other family members.     

Granada television goes to China: The choice of locations and characters

Two films about China made by Granada Television are analysed for their chosen locations and characters. Explanation for these choices is sought through interviews with the production team. Explanation centres on how their Chinese hosts steered them to particular locations and individuals, and how television's need for strong, charismatic individuals determines whose lives are shown. These conclusions are then tentatively generalised to (anthropological) films on China and elsewhere. Finally, stress is laid on the need for other production studies to test the general validity of the conclusions of this particular study.     

Beneficial Coercion in Psychiatric Care: Insights from African Ethico‐Cultural System

There is a ‘catch 22’ situation about applying coercion in psychiatric care. Autonomous choices undeniably are rights of patients. However, emphasizing rights for a mentally‐ill patient could jeopardize the chances of the patient receiving care or endanger the public. Conversely, the beneficial effects of coercion are difficult to predict. Thus, applying coercion in psychiatric care requires delicate balancing of individual‐rights, individual well‐being and public safety, which has not been achieved by current frameworks. Two current frameworks may be distinguished: the civil liberty approach and the Stone model. Both frameworks are restrictive, and not respectful of human dignity. In a civil liberty approach, individuals who are severely mentally‐ill but not dangerous would be denied care because they do not meet the dangerousness threshold or because the use of coercion will not lead to rebirthing of autonomy. This is unsatisfactory. Albeit involuntary interventions such as talk therapies, peer‐support etc., may not always lead to rebirthing of autonomy or free patients from mental illness; they can however help to maintain the dignity of each mentally ill patient. In place of these frameworks, this study proposes a new ethical framework for applying coercion in psychiatric care that is respectful of human dignity. Specifically, it draws on insights from the African ethico‐cultural system by using the Yoruba concept Omo‐olu‐iwabi to develop this new framework. This way, the study shows that only a more respectful approach for applying coercion in psychiatric care can lead to the careful balancing of the competing interests of individual's rights, individual's well‐being and public safety.     

Adaptation of children to a chronically ill or mentally handicapped sibling.

The presence of a chronically ill or mentally handicapped child in a family can be a stress for the child''s siblings, who often are ill informed about the nature and prognosis of the illness, may be uncertain what is expected of them in the caregiving role, may feel their own identities threatened, and may experience ostracism by their friends and misunderstanding at school. Although individual reactions vary widely, feelings of anger, guilt, resentment and shame are commonly reported. Excessive responsibility and concern about one''s identity may add to these feelings and culminate in psychologic problems in the sibling. The physician caring for the family must be alert for symptoms of emotional disturbance or social maladjustment among the siblings of chronically ill or mentally handicapped children and should be prepared to counsel the family or refer them to a counsellor experienced in this area. In general, the first step is to be sure that the sibling is fully informed about the condition and to encourage frank discussion between the parents and the handicapped child''s siblings.     

The elderly mentally ill--whose responsibility?

The elderly mentally ill make considerable demands on health and social services. To evaluate the need for these services a one-day census of all people aged 65 and over was carried out in an area containing 220 000 people (40 000 over 65). Data were obtained on the nursing needs and psychiatric state of the 2162 elderly people in hospital or local authority residential homes for the elderly, or living at home receiving care from the community nursing service. One-third were classified as having psychiatric problems, more than half of them being outside hospital. Residential homes and community nurses play a significant part in caring for the elderly mentally ill, and an integrated but flexible manpower policy is important.     

The new Israeli law on the care of the terminally ill: conceptual innovations waiting for implementation

Israel has recently enacted a law on the care of terminally ill patients. This law, the Patient Nearing Death Act, is the first of its kind in the world. The law divides terminally ill patients--upon their own wishes--into two separate groups: "those who wish their lives be prolonged," and those who do not. Doctors will have to abide by elaborate advanced directives and take into account various sources of information on the presumed wishes of the patient. The law sanctions discontinuation of mechanical ventilation should it become a "cyclical" rather than "continuous" therapy, a provision that has implications for the use of the already available paraPAC ventilators. The law exposes gaps in modern Judaism between the religious law and the attitudes of the observant population with regard to medical ethics.     

Introduction to "The Impact of the Hurricanes of 2005 on New Orleans and the Gulf Coast of the United States"

In this introduction, I briefly compare anthropological notice of Hurricanes Katrina and Rita in 2005 to that of the more powerful Hurricane Camille in 1969 and note pertinent developments in the intervening 36 years, especially the emergence of an anthropological specialty in the study of natural disasters. An overview of the collection follows with comments on particular strengths of each article and suggestions for some of their wider implications for research and public policy. I conclude with a consideration of possible avenues for further anthropological research on hurricanes in general and questions on recovery from Katrina, Rita, and ensuing floods specifically, thus providing a wide-angle perspective on this "In Focus" endeavor—impacts of hurricanes, disaster anthropology, and both short-term and long-term culture change.     

Area security unit in a psychiatric hospital.

Since 1974 a psychiatric hospital security unit, designed to serve the whole catchment area, has cared for mentally ill (mostly psychotic) patients with disturbed behaviour that cannot be managed in open wards. There are a few long-term dangerous patients but most stay only briefly. The admission of women to the unit was not followed by the expected reduction in violence. The unit has facilities for occupational therapy, physical recreation, work, and study, which are particularly important for those who are too dangerous to leave it. The unit''s calming influence depends as much on the supportive effect of the high staff ratio as on the use of tranquillisers. This type of unit is not suitable for patients with personality disturbances who "act out" or for mentally abnormal offenders; but it functions well as a crisis centre for the disturbed mentally ill, and there is an increasing demand for its services.     

Anthropology and mental retardation: Research approaches and opportunities

Although mental retardation is largely a sociocultural phenomenon, anthropological interest in this field has been slow to develop. In recent years, anthropological concepts and methods have been used in study of the community adaptation of mentally retarded persons and societal reactions to them. As an illustration, research developments at the Mental Retardation Research Center, UCLA, are discussed. The need for expanded, collaborative research by social and biomedical scientists is examined. The research puzzles include the links between poverty, ethnicity, schools, families and mental retardation, as well as the nature of intelligence and adaptation.     

The Dark Side of the Moon: Conceptual and Methodological Problems in Studying Rural and Urban Worlds in Peru

Recent anthropological theories deal with conceptualizations of culture and space. This article discusses these issues in relation to material from two different periods of fieldwork among villagers and migrants from a community in the Peruvian Andes. It demonstrates that their lives can only be understood when all ties of interdependence between the two groups are included in the analysis. It concludes that in a deterritorialized culture, territory plays a crucial role in people's identity, and living a double life does not imply having a double identity.     

Parallel and divergent landscapes: cultural encounters in the ethnographic space of Tuareg medicine

This essay explores the dialogue between the local quest for healing and the anthropological quest for healing knowledge, and local assessments of knowledge-power relationships in these processes. The context is medical discourse among the Tuareg of Niger Republic, West Africa, and my research experiences among these people. I examine local medical specialists and their traditional and changing practice in terms of how they perceive and respond to wider knowledge and power systems that impinge on local health care. Paramount in these systems are central state policies and medical anthropological research on healing, as these intersect in a postcolonial and post-separatist/rebellion setting. The essay analyzes parallels between the exchange of medicine and the exchange of knowledge and reflects upon how anthropological knowledge of African healing systems is constructed in an environment highly charged with power and danger--of political violence and economic crisis. The broader issue addressed here is how to give greater empowerment to local residents' voices in their "indigenous critique" of the medical anthropological project.