“I was kicking the wall and really angry,” she recalls. “I was angry about being in that building and being low income.” 

Agitated by her PTSD and unused to the culture of surveillance in her single- room occupancy (SRO) hotel, Aleta felt watched by staff and not listened to when she complained about the harsh chemicals used to clean the building. The SRO's policies started to feel like an intrusion: it prohibited residents from having overnight guests, staff installed security cameras in the building, and required everyone to check in when they entered.

Then, a flare-up between Aleta and building staff escalated to the point where Vancouver police officers detained her under B.C.'s Mental Health Act, which allows authorities to involuntarily admit people with serious mental health issues for treatment in hospital. Healthcare workers diagnosed Aleta with psychosis. According to her, she was involuntarily confined to a locked mental health ward for more than a month of observation.

Last September, Mayor Gregor Robertson and Vancouver Police Chief Jim Chu declared a mental health crisis in Vancouver and called for more assertive community treatment initiatives. Their high- profile pronouncement drew attention to mental health concerns among vulnerable populations like the low- income and homeless residents of the Downtown Eastside. Some politicians have even sought to reopen Coquitlam's Riverview Hospital, a mental health facility controversial for its traditional approaches to mental health care, to create more long-term care options for those diagnosed with serious mental illnesses.

Most would agree there is a need for more assertive kinds of care. But many working on the front lines of mental health care say the best solutions incorporate holistic, non-medical community supports like mental health outreach, supportive housing and preventative care—not places like Riverview.

Frontline workers calling for more supportive housing, outreach, and preventative care for people with mental health issues work with people like Aleta every day. Mainstream media has historically over-focused on mental health crises featuring extraordinary acts of violence in public spaces, like Tim McLean's grizzly 2008 beheading on a Greyhound bus in Manitoba.

But the majority of people diagnosed with mental illness—those whom frontline workers deal with most of the time—are more like Aleta: under the radar, largely suffering in silence, chronically under-housed and largely under-served when it comes to mental health outreach and advocacy. Aleta's gentle demeanor, grey hair, short stature and soft, kitten-themed sweaters don't fit the mass-culture picture of a person with mental health concerns.

What gets ignored

When she first moved in, Aleta felt lucky to have found affordable housing in one of the nicer SROs in the Downtown Eastside, the name of which Megaphone withheld to protect Aleta’s privacy. The rooms were spacious and the rent reasonable. But considering what she had previously survived to secure that room, she was also wary of her new surroundings.

“I've been through a lot of assaults in my life, a lot of violence,” she says. Her post-traumatic stress disorder is related to those experiences.

“I've been through the foster care system, I've done the whole gamut. So I've been very traumatized. I've been assaulted many times, I've gone through a lot of suffering in my life.”

Normally a host of coping mechanisms keep her feeling well. Things like yoga, acupuncture and diet help. But Aleta's move to the Downtown Eastside set off a string of mental health difficulties that led to anger, confrontations and eventually, confinement.

“I was kicking the wall and really angry about stuff, and actually angry about being in that building and being low-income,” she says. “I feel like being a low-income person and being on disability, you get punished for it.”

Aleta felt that her complaints and feelings were not being heard or acknowledged. Communication between her and staff was breaking down.

“People are pre-programmed to believe things about people in the SROs and in the mental health system. The concept of mental illness pre- programs people to think that you will be dangerous to yourself and other people,” Aleta says.

As the situation in her building worsened, she tried reaching out to what mental health resources she could find, but her efforts were fruitless.

“I've called the support lines. And, well, there are no support lines for mediation, helping people mediate and just talk.”

The only immediately discernible mental health supports, according to Aleta, are designed for people in extreme crisis: people who are contemplating taking their own life.

As Aleta explains, the available resources treat mental health consumers as those who, in her words, “either want to commit suicide or not.” For those who haven't yet stepped into those darkest stages of mental health crisis, “they are not there to help you or support you.”

Coercion, or treatment?

Fed up and desperate for help, Aleta eventually acted out. In what she calls an act of protest, she slapped herself in the face. “I was protesting the cleaners in the building. So I slapped myself.”

As a result,“they called the mental health team and I was taken in for over a month. They kept me because they said I was threatening to hurt myself. Which I wasn't,” she says. She had slapped herself in the face in an act of desperation, after so many other attempts to get help seemed to fall on deaf ears. “Everything I did was meant to get somebody's attention.”

When Aleta was released from the hospital, she had a court order not to return to her building and to report to a community mental health team for a bi-weekly injection of anti-psychotic medication.

She disagrees with her diagnosis and finds her bi-weekly anti-psychotic injection to be a coercive violation of her rights and her body.

Some mental health professionals argue that people may not understand or appreciate the importance of medication and treatment.

But Aleta's situation also illustrates how non-medical things like stable, comfortable housing, a supportive network of friends, and feeling included in one's community—all things that she continues to struggle to hold onto— can be just as effective as treatment at diffusing the mental health crises rampant in her neighbourhood.

Mental illness in the Downtown Eastside: “off the scale”

The experience of mental illness takes many forms, and its severity can be understood to exist on a spectrum. At the most extreme end are those who are socially disadvantaged, marginally housed, effected by severe symptoms and often living with several co-occurring illnesses. This group represents a minority of the thousands of Canadians affected by mental illness—according to the Canadian Mental Health Association, one in five Canadians will develop a mental illness at some time in their lives— but this marginalized minority is the group that lies at the centre of public discussion about mental illness. They're at the centre of Vancouver's mental health crisis that police, public health authorities and others are working hard to solve.

Bill MacEwan is a veteran psychiatrist working to better understand how mental illness plays out among DTES residents. 

MacEwan has a long and varied history of working in mental health: he opened a ward for people with psychosis at Riverview and he worked in Vancouver General Hospital's emergency room. But when he started clinical rounds in the Downtown Eastside, nothing prepared him for the severity of mental illness he observed among SRO residents.

His shock led him and others to conduct a five-year study, “The Vancouver Hotel Study,” on the mental health of marginally housed people living in the DTES.

The study, based on the experiences of 293 SRO tenants in four DTES hotels, was published in the American Journal of Psychiatry last year.

The findings are stark. High rates of addiction co-occur with mental illness. According to the study, almost all—95 per cent—had substance dependence and almost two-thirds were involved in injection drug use. According to the study, “nearly half of the participants suffered from psychosis, and nearly half had a neurological disorder. Eighteen per cent of the residents surveyed were HIV positive and 70 per cent had been exposed to hepatitis C.”

Among the study participants, two- thirds had been previously homeless and suffered from an average of three illnesses at the same time. Childhood trauma was also common among those surveyed.

The population in the DTES represents a group of mental health consumers whose history of trauma, according to MacEwan, is off the charts.“The average university student on a scale of 30 is a four or a five. These people are in the 18 to 20 range,” he says. “It's off the scale. These were serious, repetitive traumas.”

Community committal and supportive outreach 

The Hotel Study found that many in the DTES who have a mental illness are not receiving the care they need, due in part to insufficient mental health outreach, services and supports. But MacEwan, the Vancouver Police Department and the Vancouver mayors office also contend there needs to be more of what is called community committal, the use of legal tools to enforce compliance with community services and treatment.

Community committal is deeply controversial, but many psychiatrists see it as the only way to treat non-compliant patients. It gives healthcare providers the ability to administer medications to potentially unwilling patients. Critics raise concerns about individual rights and the damage that forced treatment can have on a mental health consumers' relationship with his or her caregivers.

People on both sides of the issue agree that one of the keys to successful treatment is for the system to expand outreach efforts aimed at providing active support, available at all hours, that reflects consumers' wants and needs. 

“The outreach piece is not there. The police are doing that outreach. For all the right reasons and some of the wrong ones, unfortunately,” MacEwan says. “For [treating mental] health, after 5pm, we don’t have anyone on the streets.“

Outreach work: more than service referrals

Damian Murphy is standing a few feet away from a roaring freeway onramp. It's early enough that the stars are still hanging low in the sky.

Murphy is an outreach worker for The Kettle Friendship Society, a non-profit mental health service provider. He's about to duck under the overpass to deliver bad news to a group of homeless people he's been working with for a few weeks. He thought he had found housing for all seven of them, but it turns out there is only enough for three.

Murphy looks like a Canadian David Bowie decked out in rain gear. His philosophy is to meet people where they are at, suspending judgment in order to build long-term relationships. Part of that means helping people who are homeless connect with housing, access health care, income supports and vocational training. But it also means chatting with people, handing out juice and making sure people stay dry.

Murphy stresses that outreach work is about a lot more than service referrals. It's fundamentally about building trusting, steady relationships with people who are often and, usually for good reason, deeply mistrustful of those extending their hands to help.

“There is a myth that housing and treatment don't work. But I see it every day,” he says. But the process of housing people who have lived on the streets for years is fraught with complexities. As their lives stabilize, layers of trauma, patterns of addiction and difficult emotions start coming up.

This is a crucial stage; a person is coming out of what can feel like a fog, and it can be overwhelming. Fixing broken family relationships, dealing with chronic health problems and finding work can seem hopeless. It can seem tempting to give up. In these situations, simply putting a roof over a person's head is setting him up for failure. So, too, is compulsory treatment in the absence of other supports.

A PACT to improve mental health services

A model that has been shown to work is called PACT (Program for Assertive Community Treatment). This model has been found effective for treating people who have co-occurring mental health and substance abuse related problems.

It blends a harm reduction approach with elements of clinical case management, self help, housing, supported employment and, when needed, crisis response services.

The Kettle employs a mental health outreach worker that provided services along PACT's lines. But outreach positions are often the first to go when budget cuts occur. Vancouver Coastal Health cut funding to The Kettle's mental health outreach worker position, and the organization was able to secure the position through temporary private funding from a philanthropist in Lichtenstein. The Kettle's Homeless Outreach Program (HOP), for which Murphy works, is a stable position funded by BC Housing.

There is a severe deficit in mental health outreach funding across the board, from the kind of on-the-phone conflict de-escalation that might have helped Aleta, to longer term supportive housing and treatment for those who need it.

There are many talented, committed people working towards a better future in the Downtown Eastside.

But for those sleeping rough on the streets, and for people like Aleta who are struggling to simply feel heard, change can't come soon enough.