How we treat homeless people with mental illness and addiction must change

Too often sick patients seeking help are turned away from the care they need

The “Rat Park” experiments were a series of trials carried out in the 1970s, using rats as subjects to track the effects of psychoactive drugs on the mind. The rats were kept in incredibly tight confines in tiny cages and given two bottles to drink from. One contained clean water, the other a cocaine-based solution.

Invariably, the rats opted for the cocaine water; the cocaine eventually overtook their systems and they died. The rats essentially killed themselves. It took American psychologist Dr Bruce Alexander, in the late 1970s, to ask the crucial question: why?

Dr Alexander observed that the rats’ lives had been utterly miserable in those tiny cages – isolated, in the dark. Rats, like humans, are a particularly social animal. In an inspirational flourish of anti-establishment thinking, Dr Alexander and his colleagues built Rat Park – a living space specifically made to meet the primary needs of the rats: space to run, play, eat, mate, as well as the two available bottles, cocaine water and clean water.

In this environment, the rats mostly opted for the clean water.


Not a single rat overdosed.

This experiment speaks volumes in terms of our understanding of dependencies, and how people respond to traumatic environments. It is also a clear demonstration of the need for systemic change to counter addictive behaviours.

Homelessness is an extraordinarily trauma-inducing state to live in, something I have experienced myself

There is a visible relationship between drug use and homelessness today which leaves some of us with the impression that our spare change will be “enabling”, that homelessness is synonymous with drug use, that substance misuse is something which can be resolved solely through “individual” effort. In fact, homelessness is an extraordinarily trauma-inducing state to live in, something I have experienced myself in hostels. These are brutalising environments, in which people live at their wits’ end, precariously, poor, with ubiquitous, significant and severe mental health challenges. In such environments, substance misuse (including alcohol) is widespread.


For the past year, I have been employed as a peer support worker, supporting individual peers in homelessness and mental health. In my work, the same motifs appear again and again. Of course, no two traumas are the same; in fact two people can go through the same experience and emerge with hugely different outcomes. One might be relatively unscathed, while the other might experience profound trauma. But adverse childhood experiences come up in spades, as does, almost inevitably, stigma. There is an implicit notion that homeless people “just need to get themselves together”, as if they’re solely to blame for their situation. Substance misuse (including alcohol) is a natural way for homeless individuals to try to dull the pain of such a traumatic existence.

Dr Fiona O’Reilly, chief executive of Safetynet (which employs general practitioners, nurses and support workers to provide services to homeless people and vulnerable groups), shared her thoughts and insights into the trauma-infused world of homelessness and drugs: “You could say, ‘Yes, drug use is there and that is often why people become homeless.’ But there is also the fact that drug use becomes more chaotic in homelessness. And then people who were never using drugs start during homelessness. And we do know that people start using drugs in the hopelessness of homelessness.

The homeless environment provides the means to numb that pain, because there is drug use in every hostel

“If your environment is not a healthy environment, your security of shelter is not there and you’re lacking a home, which is a different thing to shelter . . . of course you will look for ways of numbing the pain. The homeless environment provides the means to numb that pain, because there is drug use in every hostel, within the same rooms that you are sleeping in. They can become new patterns for people in those surroundings.

“Going for the clean water in this would be a healthy environment, your own room, some supports, some connection. All of those things would be the clean water. And that’s not even there. Even if it was there, you could imagine people would still maybe choose drugs because there’s other things going on for them. But it’s not there; it’s not an option.”

We can clearly extrapolate the link between drug use and traumatic living environments. O’Reilly also mentioned that in these chaotic situations “you don’t know who is sleeping beside you”.

‘People suffering’

In my own experience, in the hostels, recantations of horrific past experiences are commonplace. Aimee, a homeless former drug user, recounts several such experiences, which can lead to life-long adverse events: “Both of my parents were addicts. They died when I was young. I guess life really got messy after I got kidnapped at 12. I buried that for a long time. To this day I wake up in a sweat dreaming about it . . . I thought those men were going to kill me. I was just in the boot of the car thinking, ‘Nobody knows where I am.’”

Aimee lives with the fallout of these surreal, horrifying events: “I started getting PTSD then when I was 15. Just constant flashbacks and nightmares. But the first time I totally lost me head was when I was 18. I thought there were worms crawling all over me. I’ve been in and out of the psych wards since my teens because of those kinds of thoughts.”

Aimee draws a clear connection between dual diagnosis, when a person suffers from both a substance abuse problem and another mental health issue, and homelessness: “I wound up homeless after a stay in a psych ward. I was always given tranquillisers. Then when I was staying in the hostels I totally lost the head. There were dealers living there and they kept offering to give me trays of tranax [strong, street xanax]. Eventually I caved in. I didn’t care about my life anymore. There was nothing but drugs and people suffering. Not the worst hostel in town, but it was bad enough.

“I already had PTSD and chronic anxiety before I went in there. Everything just got worse. My head was totally out of joint. I really felt like I wanted to die. I think a lot of people in there felt the same. It’s a horrible way to be.”

In fact, the services aren’t designed to assist those experiencing dual diagnosis. Aimee recounts her battle to get into treatment: “I went four times to the A&E and got turned away because I was too sedated. Then I went to the nearest psych unit with a letter from my GP but they said that the funds weren’t there to do a detox. I was desperate. It was only with the help of a brilliant GP who works with homeless people that I started to cut back, back, back, bit by bit. It was pure luck she accepted me because nobody wanted to take me on. It only made me feel more worse . . . I felt like a waste of space.”

Cracks in the system

Safetynet cite a rough figure of 80 per cent of their homeless cohort, who present with mental health challenges, having dual diagnosis. Aimee’s fight to get sober shows up some serious cracks in Ireland’s treatment infrastructure. If you approach a mental health facility, you’ll be told to return once you’ve treated the addiction. At an addiction centre, you’ll be told to treat the mental health issue. It is often assumed that mental illness and dependency behave in a “chicken and egg” scenario, that one fuels the other.

However, there is considerable evidence to suggest that both elements of dual diagnosis are interwoven and completely cross-fertilised. Turning away a sick patient seeking help from the emergency department seems like a violation of human rights. Aimee went there – suffering and desperate for help. To be refused access to mental health facilities shows how people with dual diagnosis fall through the cracks. The fact that budgetary remarks were made to Aimee about refusing her treatment is unacceptable; dual diagnosis is a potentially fatal state – through overdose or suicide.

I asked Dr Austin O’Carroll, a GP who specialises in providing medical care to the most marginalised, about the relationship between drugs and homelessness. According to O’Carroll, “What the evidence shows is that the vast majority of those in drug addiction and homelessness come from poverty, and the vast majority have a background with childhood adversity. And childhood adversity is also strongly associated with poverty. So childhood adversity and poverty are the two key preceding states for drug use and for homelessness.

"How many of you know of drug use or someone who has died?" and practically most of the class will put their hand up

“To give an example I often go to medical students, and in a medical class I did there was a group of around 300 medical students. I asked, “How many of you know someone who’s a drug user?” And with drugs, I was talking about heroin and crack cocaine. About seven or eight people put their hands up. Then I asked, “How many of you know someone who has died of drug use?” And two or three people put their hand up. You go into an inner-city school and you ask in a primary school, “How many of you know of drug use or someone who has died?” and practically most of the class will put their hand up. It is so prevalent in inner-city areas where there is deprivation and drug use. That was a big shock for me, when I suddenly went into this whole community which had been devastated by the young deaths, because there had been so many people addicted to drugs.”

All too often, we set homeless individuals apart from ourselves, labelling them “weak” or, worse still, “junkies”. We would do better to consider what we have in common, what we share; to consider homeless individuals as people, some with more complex needs than others. For a start, we need a complete systems overhaul on how we care for people experiencing dual diagnosis – particularly for homeless individuals who are the most structurally vulnerable of all. For too long the dual diagnosis issue has been shelved by the Health Service Executive. It is crucial that people get seen to at the moment of reaching out. Left too long, they are at risk of death. As Aimee’s story tells us, care isn’t available at all, let alone waiting for an integrated system to provide assistance.

There needs to be psychiatrists with specialisation in addiction, therapists, activities, jobs within the centres with a hope of continuation outside – something meaningful. And they all need to be working in a multidisciplinary way. There should also be housing supports available. But these structural changes will never happen until we can simply acknowledge the humanity of the homeless people we encounter on the street, and be thankful for our privilege.