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Sleeping rough: Homelessness and mental health

The recent death of a popular homeless man in Neukölln highlighted the immense challenges faced by mentally ill Berliners living on the streets. We speak to people on both sides of the story.

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The recent death of a popular homeless man in Neukölln highlighted the immense challenges faced by mentally ill Berliners living on the streets. We speak to people on both sides of the problem. Photo: IMAGO / Rolf Kremming

The recent death of a popular homeless man in Neukölln has brought to the fore the precarious situation of mentally ill Berliners who live on the streets. With an estimated 80 percent of Germany’s homeless suffering from mental disorders, is enough being done to help them break the vicious circle?

Marco may have been homeless, but in Neukölln’s Schillerkiez, he was part of the neighbourhood. The locals, put off at first by his appearance and occasional psychotic episodes, had eventually grown accustomed to his presence. They began to chat with him, often bringing blankets, hot drinks and food. Syndikat bar let him sleep on the sofa; a café was exhibiting his art. Things were looking up for a man who had spent years bouncing around the city without stability. Then the pandemic hit. When Syndikat was evicted, Marco returned to sleeping on the streets, and his psychotic episodes became worse. Social workers regularly went to look for him, but either they could not find him or he rejected their help. He died in a doorway on January 8, at the age of 33.

According to his childhood friend, Max Thommes, Marco’s mental health deteriorated gradually over a long time – and his condition was worsened by being homeless. “I think it was a bit hand in hand,” Thommes says. “I think he landed on the street because his mental state was so bad, but it definitely got worse.” Marco would go to hospitals, but he never seemed to emerge with long-term treatment or a therapy plan. “When he got pills, he would never take them. He didn’t have the chance to really clear his mind.”

It is surely no surprise that mental health problems and homelessness are interdependent. A recent meta-analysis of studies found that 77.4 percent of homeless people in Germany suffer from mental illness. While mental illness makes homelessness more likely, and more difficult to escape, being homeless tends to exacerbate the existing mental health issues of people who are already vulnerable – often to a dramatic degree. In Berlin, as elsewhere, this destructive cycle is furled by avoidable limitations in the state’s provision of care, from therapy units and follow-up care to the availability of safe public housing. Without a safe place to live – and without sufficient support – mentally ill homeless Berliners face vast challenges as they seek to improve while navigating the traumatising, destabilising conditions of life without a home.

“I took drugs to be able to endure”

Sara grew up in a small town in Sachsen- Anhalt, where her parents owned a company. Well-known and respected in the town, they were by all appearances a model family. “But inside everything was shit,” Sara explains. “My dad would beat us often, and badly.” Sara developed psychological problems from an early age, including panic attacks, severe depression, an eating disorder and self- harming behaviour. At 11, she started running away from home – at first for days, then weeks, then months. By age 13, she was living permanently on the streets.

“Living on the street is hard, especially in winter,” Sara recounts. “I consumed a lot of drugs and alcohol – it helped me forget the pain, forget life.” Soon, her psychological problems were compounded by addiction to amphetamines and heroin; she even turned to sex work. “I spent my days trying to get hold of drugs and money. In my head was always the thought, hopefully I wouldn’t survive this.” Sara was admitted twice into a psychiatric clinic during this time, but both times she ran away. Eventually, at 16, she found herself before a judge who gave her an ultimatum – either a drug rehabilitation clinic or juvenile prison. Sara chose the clinic. Supported by her mother, who re-established contact, Sara improved and was released after nine months. Now, years later, she still celebrates the date of her first day at that clinic – her “second birthday”.

“This year, I’ll be 15,” she says proudly. “Since that day I’m clean.”

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Marco may have been homeless, but in Neukölln’s Schillerkiez, he was part of the neighbourhood. Photo: Leander Jones

Sara’s story is illustrative of the many people who become homeless because of factors beyond their control – abuse, trauma, economic distress and much more. Dr. Stefan Gutwinski, a specialist in psychiatric care for the homeless in Wedding, estimates 50 percent of Berlin’s homeless have a background of childhood trauma and 50 percent come from foster care; around a third did not finish school. Sleeping rough takes a significant psychological toll on already-vulnerable people, who then face an even harder path towards finding safe accommodation.

Sara recalls that, alongside the general worsening of her condition, she developed serious anxiety problems because of the “constant fear and danger” of life on the streets. Her addiction, too, arrived when she became homeless. “I took drugs to be able to endure life on the streets,” she says. In the meta-analysis that found 77.4 percent of German homeless people having mental illness, it was also reported that many have overlapping psychological disorders – the most common overlap being substance addiction, commonly a means of coping with trauma.

To finding a home of one’s own

Sara’s eventual recovery was empowered by having access to a secure place to stay, removing the stress of homelessness from the equation. When she was released from the clinic, the Youth Welfare Office found her an apartment, with rent paid by the Job Center. “The flat was so important for me,” Sara remembers. “I had a space for myself that was safe, where I could do what I wanted.” Sara’s father had been puritanically clean: if she left a cup somewhere, he would throw it at her. “In my flat, I could leave the cups wherever, I didn’t have to do the dishes, I could dress how I wanted,” she says. “They’re little things but they’re important. If I’d had to go back to my parents’ house, I would have just been homeless again.”

Sara began seeing a therapist three times a week. With the help of a counsellor, she got her life back on track – she finished school and completed an apprenticeship as a social assistant, began working with disabled children, then had a son of her own. Now she volunteers to help the homeless. While she still has difficulties, including episodes of depression, her situation is greatly improved. Not only is Sara glad to have a stable environment, but – as she recounts – “I now have enough self- awareness to know when to ask for help.”

“I spent my days trying to get hold of drugs and money. In my head was always the thought, hopefully I wouldn’t survive this.”

A home doesn’t always mean an apartment. In a park off Prenzlauer Allee, right near the bourgeois-bohemian heart of Prenzlauer Berg, stands a cheery green cabin. Here lives Steve – or “Crazy Steve”, as this large, bearded man is affectionately known. A neighbourhood fixture, Steve is known for liking a chat and for sharing a deep store of unlikely tales about his past. The local community has taken him into their hearts, with one small business owner having paid for his hut – Steve used to sleep in the ATM room of the local post office, and then, when they locked it at night, on a bench.

Currently, Steve seems to be doing alright – so long as he has his hut. But a sudden loss of accommodation, or a sudden change in living conditions, can have disastrous consequences for Berliners caught in the nexus of homelessness and mental illness. It was after the closing of Syndikat bar that Marco, returned to the instability of street-sleeping, had progressively worse psychotic episodes and began refusing help, until his death.

[Note: Steve passed away on Sunday, March 23. Here’s our final interview with him.]

Dis/continuous care

While research has long been unclear on whether homelessness causes mental illness or vice versa, a series of recent studies suggests that mental illness precedes homelessness for a significant majority of cases. According to Dr. Gutwinski, this reflects poorly on the psychiatric care system. “This is a sign that the net for our patients is not good enough,” he says. “We don’t reach the very ill people early enough, and as a result they become homeless – and then it is much more difficult to help them.”

In particular, Gutwinski believes better care must be taken of patients after they leave psychiatric clinics – especially those with psychosis or substance abuse problems. The Wohin study on homelessness in Berlin hypothesised that people with more severe mental illnesses tend to be treated involuntarily but then discharged once the legal basis for compulsory hospitalisation has run out. This lack of follow-up care means patients are sometimes discharged without a clear way forward, left to fend for themselves. “It is important that they are not left alone,” Gutwinski says. The result can often be homelessness, and with it a slip further into the vicious cycle.

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An outreach project called Housing First aims to put homeless Berliners into accommodation immediately. Photo: IMAGO / Frank Sorge

Another major problem for psychiatric care is the scarcity of available housing. “Ten years ago we could focus on treatment mainly,” Gutwinski says of his clinic. “Nowadays, when patients come to us, a large amount of our time together is spent on trying to solve their housing problems.”

Gutwinski, for his part, aims for the rooms of his clinic to look more like flats than a hospital: “There are three beds and you can bring your family and friends, who can sleep there for free.” More broadly, Gutwinski believes accommodation for the homeless is a major lack in the psychiatric system. “Just imagine someone wants to talk to you in these cold temperatures in a train station and offers psychological support,” he says. “This is not what you need. You need a room to sleep, to put your stuff, to relax – and then you can start thinking about psychological problems.”

Breaking the cycle

An emerging consensus among psychologists and social workers sees “Housing First” as the best bet to break the cycle. Housing First turns the traditional approach to homelessness on its head, explains Ingo Bullerman, who leads the social services agency NeueChance and has run a Housing First project in Berlin since 2018. “Normally you have to undergo a help plan involving a lot of duties like reducing drinking, using psychiatric help, working on your problems – only at the end of a long process do you get a flat,” he says. “But often it doesn’t work, because the barriers are too high.”

With Housing First, participants are given a flat from the beginning, no questions asked. The logic is that, by providing people with a safe and stable environment, they will be more capable of developing their own resources, making their own targets and taking steps towards recovery.

“Just imagine someone wants to talk to you in these cold temperatures in a train station and offers psychological support. This is not what you need. You need a room to sleep.”

“Being homeless is very overwhelming, with constant existential needs, dangers, and fears,” Bullerman says. “So it’s very difficult for people in this situation to think about their mental health or stick to a plan.” Housing First interrupts the circuit by ensuring its participants begin with stability. Naturally, doing so entails a risk – Bullerman notes the story of one man who left two flats he was brought into, being paranoid about the neighbours. But the overall picture is promising for Housing First. Finland, where it has been general policy since 2008, has seen homelessness has fallen by 30 percent In Berlin, unfortunately, the project has been limited to just 40 flats due to – of course – the shortage of public housing.

Stories from homeless people such as Sara also support the power of having accommodation early on. “You can become more healthy when you have a home, a base,” Sara reflects, “though that does not need to be a flat you pay rent for – there are different forms of living. But for your psychological and physical health, you need a base where you feel at home. A safe space.”