At the edge-lands of mental health care, whose vulnerability counts?

For our first guest contribution we’ve invited Natassia Brenman, a PhD student from LSHTM, to share her work on access to community mental health services in London. 

I don’t think I ever met the two homeless people who had been sleeping outside the counselling service I spent time volunteering at last year. I’d been there as part of a piece of research with mental health charities in London, which (with the mainstream system currently bursting at the seams), have become more important than ever as places for people to come to in their darkest hour. But these two had come hoping to make use of the sheltered doorway of the centre, rather than the listening ear of a volunteer counsellor, and fairly quickly it was decided that this went beyond what the service had to offer.


And so by the time I arrived there, all that was left of the homeless pair were a jumble of vague stories, a few traces of their existence: there was the mention from the receptionist that one of the pair had popped up in the Tesco’s car park a few streets away, astonished that she’d recognised him (“I think he thought he was invisible!”); sometimes people talked about the “night revellers” that used to leave glass bottles whose broken shards would shine in the gutters; and then there were murmurs that the mess between the breeze-blocks at the bend in the road was in fact human excrement, which apparently they used to have to get rid of with buckets of bleachy water, sluiced through the half-cobbled, half tarmacked terrain of the cul-de-sac.


Like so much of inner-city London, the neighbourhood is being bought-up and developed at a rate so fast it can’t keep up with itself. Despite the soaring property prices and quick turnover of shop fronts, there remain large enclaves of deprivation and buildings that haven’t been touched for years. The 1960s block behind the service sits unused, as does the old gasholder behind the wire fencing. The cul-de-sac in which the service is based is privately owned, and so the responsibility to maintain it lies with the landlord and local residents. This probably explains the unfinished tarmac job, the abandoned cars that lined the opposite side of the street, and the sign, imploringly hand painted directly onto the red-brick house at the end: “No dumping!”


When the charity’s chair of trustees came in for a meeting one day a year or so ago and saw the two figures with their sleeping bags and cans scattered around them, she would have known that— without someone personally intervening— it was likely they’d still be there when next month’s meeting came around. And the next. It was unclear from the titbits of story I gathered from the longer standing members of staff whether the fears about the homeless duo’s aggression ever actually played out (mostly people described them in general, slightly euphemistic terms such as being “unlovable” and “making a mess”), but the trustees all agreed that they needed to go.


Julie, one of the administrators, was enlisted to call the police, in the hope that they would resolve the situation. She told me about this looking out sideways from behind her computer monitor, an elbow on the desk, looking defiant. She hadn’t wanted to call the police; her conviction was “either you help someone with your whole heart, or you just leave them be”. But they kept asking, and she didn’t think they would have appreciated her opinion. So she kept calling, until they were gone.


Months later, I was asked to come to one of the trustee meetings to present some of my research findings about their service users’ experiences of accessing counselling. I had been interested in what it had felt like for new clients encountering the service for the first time. One of the people I spoke to— I called her Claire— had never accessed a mental health service before. She had been waiting to see a bereavement counsellor on the NHS for almost two years, which had left her feeling mistrustful of promises of free care and support. Approaching the charity for her initial assessment, her heart had sunk when she saw the rusty sign and deserted cul-de-sac. She’d had a strong sense that there could be a man in the bushes, waiting to jump out at her, and there wouldn’t be anyone around to help.


As I recounted this to the board of trustees and management of the charity, amongst tea and biscuits and home-made rock-cakes, they listened intently, their faces tired and concerned. When I finished talking, it was the imaginary man in the bushes that seemed to have captured everyone’s attention. One of the board members informed me that this wasn’t so far from the truth, that there had in fact, last year, been two men hanging around outside the service. I of course knew exactly whom she was talking about. Without going into exactly how they had managed to get them to “move on”, the chair explained that they were no longer there to upset vulnerable clients coming to the service. She made eye contact with me as she said the word “vulnerable,” signalling to me that Claire’s story had been taken seriously, that her vulnerability was something that they were accountable for.


It made me feel deeply uncomfortable that (read backwards at least) my research findings seemed to be justifying the forced removal of the two homeless people, and suggesting that further ‘cleansing’ of the area was necessary to protect clients like those who had participated in my study. Perhaps more uncomfortable, was the truth that Claire was vulnerable and that the threat (real or imagined) of encountering strangers in this space was heightening the fears and anxieties that had brought her to the service in the first place.


But my discomfort wasn’t just about unwelcome truths. It was about the fact that the story I heard was precluding some important questions being asked. The first was about what was being made invisible through the actual removal of the two men, and the subsequent haze and ambiguity in which the story was shrouded. The threat that they actually posed was obscured by the euphemistic ways of talking about how they were putting clients off, and by the conflicting stories about how and why they were removed in the end. Oddly, amongst all of the perceived threats in this story, only one came to fruition: the threat from the trustees to forcibly reclaim the space that had at some point seemed a safe place to inhabit. Also made invisible, was the men’s vulnerability. Despite the references to street drinkers or night revellers, the traces of makeshift bed and toilet suggest that this had been a site of a very precarious existence, which had of course in the end been criminalised and dismantled. Ultimately, this process of invisiblisation seemed to answer the question (before it had been asked) of whose vulnerability counts.


Mental health problems and homelessness are without doubt closely intertwined issues in inner city contexts like this, particularly as services in both areas continue to be cut across sectors. The small charity I have been talking about hasn’t chosen to take on this particular intersection of disadvantage, and nor is it their responsibility to so. They have decided to focus on the needs of a different client group, who are also vulnerable and have needs that often aren’t met by mainstream services. But maybe a useful question to ask is whether this decision really has to be a trade-off, whereby helping some necessitates the removal of others? This could help us hold in sight multiple vulnerabilities, some of which we can address, and some of which we could simply, as Julie says, ‘leave be’.


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