‘The happiest taxpayer I’ve ever met was a homeless asylum seeker’

Through the story of one patient, Dr Paul O’Reilly shares how GPs can challenge the political narratives surrounding asylum seekers and mental illness

Even I, the most amateur of GP psychiatrists, could spot the diagnosis from the other side of the street. The man was laying out, covered only by a single blanket, in the exact geometrical centre of Westminster piazza in front of the dark mass of the cathedral at 2AM on a cold, dark, bitter January night with the rain stair-rodding off the stones. All around in the shop doorways on the edges of the square, other rough sleepers huddled as best they could into their sleeping bags, trying desperately to be out of the rain and the cold. He alone lay out in its full force.

Within my experience, there is only one condition which causes its sufferers to choose voluntarily to expose themselves in all weathers in order to be out in the open, so as to be able to see their enemies coming. That is, of course, paranoid psychosis.

We approached cautiously. Paranoid people rarely welcome strangers on a cold dark night and It is never a kindness to wake a rough sleeper unless you have something notably better to offer him than his current resting place. The best we could offer was a camp bed in an emergency shelter, but that surely had to be an improvement on the status quo.

But he was not asleep and responded pleasantly. Yes, he did need to be out here to watch for the demonic army which constantly threatened him. They had pursued him here even from his native country and across a thousand miles of Africa, through the dreadful small boat voyage across the Mediterranean and through four European countries to this spot.

He had leave to remain and had briefly been accommodated by the Home Office. Apparently, he did indeed have a well founded fear of persecution underlying his paranoia. I learned once again that just because you’re psychotic doesn’t make you wrong. And now, with his case determined in his favour, he had the same rights as any British citizen to sleep where he could.

It did help him to be close to the church, but he could not take advantage of its capacious doorways because he still he needed the full 360 degrees field of view to see his enemies coming. He had seen us coming all the way along the street but had felt reassured that we seemed to chat pleasantly with all the other people sleeping there. He could see people’s auras and told us that we had good ones. But no, he did not feel this confidence could extend to accepting our offer of shelter for the night. He felt safe where he was and he had slept in worse places than this. Nevertheless, he was willing to accept my card and visit me in the surgery; he needed something for his constipation.

Our assertive outreach psychiatry service suggested aripiprazole. So, when he came, we helped him with his constipation, but also suggested that we might have something to help him cope with the tremendous fears he experienced from the constant onslaught of his enemies. It had helped others in similar circumstances. He accepted with alacrity.

Within weeks, his fears had receded such that he was able to accept hotel accommodation and as he improved, permanent accommodation in a tiny bedsit. And he was filled with thanksgiving for all that had been done for him. His only adverse effect was that he could no longer see auras. But that no longer mattered, because all of the people he met now were so good to him. This was such a wonderful country, he said, that had such fitting people.

And for some years, that was how I thought his life would be: a man with a well-controlled but permanently disabling psychosis who would at least live out his days in peace. But I was wrong. Just recently, he came to see us bouncing with such excitement that I wondered if we might have overdone the sertraline and made him manic.

But in consultation, he told me the source of his joy: he was now a taxpayer. I warned him that it was a joy which got old quickly. But he was now so incapable of fear that he did not believe me.

In an increasingly politicised climate that scapegoats and polarises the population, it is our quiet duty as GPs to offer continuity, clinical care and humanity to those who need it most – including asylum seekers. His was one of many cases that reminded me that the consulting room (or street!) is often where displaced people can find their first real moment of safety.

Dr Paul O’Reilly is a GP partner in London who works for homeless people