Doing the right thing — Ethical and practical dilemmas in working with homeless mentally ill people

Abstract

Psychiatric work with homeless people has generated a particular style of service. It involves elements of assertive outreach assessment, case management, assertive treatment, and close relationships with the voluntary sector. This activity has thrown up a number of practical and ethical dilemmas. Some of these are generated by the relationship between the patient and the practitioner, others are generated by the relationship between practitioners and the wider service network within which they work. These problems include the conflicting principles of paternalism and autonomy, the boundaries of medical confidentiality and the limitations of the Mental Health Act. Although this work is highly specialised, it includes most of the essential activities of urban community psychiatry, and so the instances described have a wider relevance to community psychiatry as a whole.