Unmet needs in street homeless people: a commentary on multiple interconnected needs in a vulnerable group

Prevalence

Since the economic crisis in 2008, the number of people registered as sleeping rough has increased, with a peak in 2017.⁴ The official governmental yearly count shows a 165% rise in numbers of people sleeping rough on a given night between 2010 and 2018.⁵ The rise has been attributed to austerity and welfare changes.⁶ During the COVID-19 pandemic in the UK, the ‘Everyone in’ policy facilitated access to accommodation for 37,000 people sleeping rough or at risk of homelessness.⁷ Rough sleeping reduced by 33%, but since the end of the policy, numbers have increased again. In 2022, the count of people sleeping rough was 3069, which was a 26% increase compared to 2021. 48% of the people sleeping rough did so for the first time.^2,5 The success of ‘Everybody in’ highlighted the importance of political will and funding in tackling rough sleeping.

Recent studies show that 83% of rough sleepers were male and 64% were UK nationals.⁵ 60% have problems with drugs or alcohol⁴ and 50% self-reported mental health needs.⁸ Other research suggests alcohol dependence ranges from 8.1–58.5% and drug dependence from 4.5–54.2%.⁹ Psychotic illness is 50–100 times more prevalent than in the general population.¹⁰ Learning difficulties and problems with communication are also significantly more prevalent in the rough sleeping population than the general public;^11,12 51% of homeless people lack the basic English skills necessary for everyday life.¹³

There is a significant risk associated with rough sleeping. The mean age of death for rough sleepers is 44 years for men (compared to 76 years in the housed population) and 42 years for women (compared to 81 years).³ The three main causes of death are accidents (mainly drug poisoning, including accidental overdose), liver disease and suicide. In 2018, numbers of street homeless people who died by suicide increased by 30% compared to a 5% increase in the general population.

Adverse childhood experience (ACE)

The causes of homelessness are complex, with external factors such as access to housing, unemployment and personal factors including relationship breakdown playing a significant role. The journey to becoming homeless varies for each person but a common significant factor is the concept of adverse childhood experiences (ACEs) such as childhood abuse (physical, sexual, emotional, neglect), parental addiction, bereavement and poverty. ACEs are common, with 54% of street homeless people reporting ACEs compared to 3–4% in the general population.¹⁴

ACEs contribute to impaired social and neurodevelopment as well as to poor physical and mental health outcomes in adulthood.¹⁵ It is estimated that 25–33% of street homeless people have been in the care system.^16,17 ACEs contribute to ill health and play a factor in how the service user looks after their health and social wellbeing and how they relate to the staff who provide care.

Trusting others is a common difficulty, which means seeking help is less likely. Interpersonal attachments to others can be impaired in people who have experienced ACEs, which can manifest in avoidant, anxious or ambivalent relationships.¹⁸ The impaired attachment pattern affects how the person seeks help and in turn influences the responses they receive from services, compounding the stigma and rejection.¹⁹ Social isolation and disenfranchisement from social networks are common, with 61% of homeless people reporting loneliness and 41% as feeling undeserving of help.²⁰ There is a large element of shame and guilt in the group, which further complicates relationships and seeking support for health needs.

In short, the homeless person may not only have to deal with physical and mental health problems from living on the street, but also the effects of adversity from earlier years that influence their physical, mental health and ability to navigate complex systems and trust others.

The concept of trauma-informed care (TIC) helps to inform how best to approach working with people who have experienced ACEs, including homeless people. This concept focuses on understanding how trauma impacts on the person and more importantly how systems can avoid repeating traumas and abuse.²¹ The system may not recognise the abuse it is perpetrating, but actions such as declining referrals because a person is homeless may occur.

Beale²² has spoken eloquently about how the mental health system has conspired to encourage staff to make decisions that fit the system and not the person. The system not only traumatises service users seeking help, who can experience the support offered as neglectful or even abusive, but also the staff working within it, in a process of moral injury.^19,22 The burnout rate in staff working in homeless hostels is high.²³

At times, the homeless person is deemed to have capacity when they appear to choose to live on the street. The term ‘lifestyle choice’ is often invoked when services decline care to the person. Both capacity and the term ‘lifestyle choice’ should be challenged by all professionals. The person's road to homelessness is often one of adversity and inequality and therefore living on the street is rarely an informed choice but an outcome of the challenges. The term ‘lifestyle choice’ is often in response to the hopelessness professionals feel when dealing with complex and multiple unmet needs that are difficult to understand or manage.

The extreme nature of severe and multiple disadvantage was often said to lie in the multiplicity and interlocking nature of these issues and their cumulative impact, rather than necessarily in the severity of any one of them.²⁴

How do mental health needs manifest?

Mental health needs manifest in many ways, from conditions fitting diagnostic criteria to psychological difficulties interpreted as mental illness. 50% of rough sleepers report mental health problems and rates of psychosis are 50–100 times higher than in the general population.¹⁰ Estimates of the prevalence of mental disorders in the homeless in western countries suggests rates of psychosis of 2.8–42.3% and of depression of 0–40.9%.⁹

Service users with psychosis often present with negative symptoms, characterised by functional decline and significant self-neglect. The psychosis is often late-onset and by the time the person is on the street, positive symptoms such as hallucinations and delusions may be reduced and the main presentation may be of chronic self-neglect. The absence of overt positive symptoms makes a diagnosis more challenging for the professionals. Diagnostic overshadowing by alcohol and drug use often means that psychotic irritability and aggression are reframed as a personality trait. Diagnostic revision from a psychotic illness to a personality disorder is not uncommon. The ‘downgrading’ of the diagnosis from a serious mental illness to a personality disorder complicated by drug use provides health and housing services with an excuse to discharge their responsibilities of care.

Common psychiatric conditions such as depression and anxiety are prevalent and impact on overall functioning and managing day to day life.²⁵ Sometimes, self-management of symptoms with substance misuse conceals underlying trauma and mental disorder and is given as a reason to avoid prescribing medication or referring to psychology.

48% of rough sleepers have reported a traumatic brain injury (TBI), compared to 21% of a non-rough-sleeping control group,²⁶ with 90% sustaining their first TBI even before becoming homeless. The TBI in turn can impact on functional abilities such as organising daily living and navigating the often bureaucratic system which should otherwise help vulnerable people.

Assessment of mental health can be challenging, due to problems with locating service users, reluctance to engage (partly due to experiences of exclusion/stigmatisation from mainstream services, including health and housing) and lack of a collateral history. In mental health history taking, the collateral history is essential as part of a mental health assessment to provide developmental history or to confirm changes to functioning or personality. However, social isolation and dislocation from family and friends reduces opportunities to gather collateral information to inform a more holistic psychosocial understanding.

What unmet needs are seen?

Street homeless people may have untreated physical problems and mental health and psychological issues, issues with substance abuse and other social needs, and in many cases a combination of the above. One study²⁷ found that the homeless service user had on average 7.2 long-term conditions, which far exceeded the number in the general population. They were at risk of premature aging and frailty and a reduced access to palliative care.

Health services often struggle with complex multimorbidities or unmet needs and will deal with this challenge by requiring resolution of problems before follow-up care is provided, when in reality the problems are intertwined and a joint approach would be more appropriate. Examples include a person not being accepted for psychological support due to housing status, mental health services not accepting patients due to addiction, and brain injury units not accepting patients due to homelessness. This approach results in delays in access to care for the service users, late presentations with worse outcomes and falling in gaps between services. The concept of multi-agency working is essential in tackling health care needs, but the reality is that often the person's care is provided in sequential silos, which is the antithesis of integrated care.²⁸

Practical issues such as lack of an address to send appointment letters to or regular moves between temporary accommodations make access to care a challenge.

Working with homeless people

Summary

The street homeless group are often vulnerable and have complex unmet needs which makes engagement by services difficult. There is a high prevalence of mental ill health and psychological challenges, often compounded by physical health problems or substance misuse. Person-centred, trauma-informed, integrated care is essential. The therapeutic relationship requires professionals to be reflective and flexible in their approaches. Health and social care systems struggle with flexibility but simple steps can go a long way, such as accepting referrals based on needs and not demographics. A friendly approach and tolerance goes a long way to engage an otherwise stigmatised group. Each contact is an opportunity to understand the needs and develop a trust which means the person is more likely to accept care in the longer term.