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

ABSTRACT
Street homeless people face stigmas in addition multiple unmet needs, which may include physical, psychological, mental health and social needs to name a few. Their life expectancy is shorter than that of the general population. Mental health problems are common but street homeless people face considerable barriers accessing support. Institutional approaches from the health system re-traumatise street homeless people seeking care and cause moral injury and burn-out in staff. Given high rates of trauma in street homeless people, trauma-informed care approaches should be used. Professionals should make every contact count, using it as an opportunity to build trust with honesty and consistency and find out what matters to the person, as well as taking practical steps such as ensuring a means of contact. Engaging with the person's wider support system, such as support workers from homeless organisations, is key as they may have a good understanding how the mental health affects the person.
Introduction: homelessness
Homelessness can take on a number of forms, including sleeping rough on the street, sofa surfing (moving between friends' and family's houses) and living in temporary accommodation. The temporary accommodation in turn can be anything from a more settled flat/house to a bed-and-breakfast, hostel or hotel.
All forms of homelessness share challenges relating to a complex interaction of social, physical and psychological issues. The factors contributing to the complexity of homelessness include structural, societal and economic factors and inequalities, such as poverty and deprivation, unaffordable housing, unemployment, exclusion and discrimination.1
This commentary will focus on street homelessness (rough sleeping) and people who are earlier on in the stages of moving into temporary accommodation. This type of homelessness is often categorised as single homelessness. We will use the term service user to describe the person who is homeless, recognising that in other health and social care setting alternative terms such as patient, client, resident, survivor and citizen are used.
Homelessness is a symptom of wider socioeconomic challenges as well as life experiences. This commentary acknowledges that social and political factors are facilitators for homelessness, but due to the nature of the publication the focus will be on mental health presentations of homelessness. This is not to diminish the importance of political and social factors, detailed in the 2022 Kerslake report,2 in contributing to or resolving the issue of homelessness or to insinuate, in any way, that the responsibility for homelessness wholly lies with the affected person.
People who experience homelessness experience inequality in health, with poor health outcomes and life expectancy shortened by 30 years.3 The person may have a combination of health needs including physical, psychological, mental health and addiction issues. Homeless people are subjected to considerable stigmatising assumptions, such as homelessness being due to addiction or lifestyle choice, but these assumptions are not borne out by research. For example, while there are a range of estimates, research shows that 40–57% of street homeless do not misuse drug or alcohol.4 There is variability in the research but what the studies have in common is that the actual numbers are not as high as perceptions of addiction in homeless people. We will further discuss the stigmatising assumptions below.
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
Become familiar with the concept of trauma-informed care (TIC)
This is essential in working with homeless people and equally applicable to the rest of the population. TIC emphasises the concept of ‘what has happened’ rather than ‘what is wrong’.21 TIC brings an attitudinal shift in the professionals which is essential in working with a group who experience stigma and exclusions. NICE guidelines1 warn against fragmented, rigid and siloed services and the impact this can have on homeless people. It is this tolerance for difference in people and flexibility in approaches to care that allows professionals to engage with and support the service user.
Be consistent, predictable and allow time for people
For many, trusting professionals is difficult, so consistency and time is an important intervention. If there is already a record of a person's traumatic history it may not be helpful to ask the person to repeat the narrative, which can be painful and often serves no added therapeutic value. Often staff will make referral for follow-up knowing the person is unlikely to either attend or to be accepted for care. This means another rejection for the person (or by the person), reinforcing the struggle with relationships and trusting others. Referrals are important but staff should consider this dynamic and discuss it with the person and the agency they are being referred to. Honesty and genuineness helps with any engagement.
Ask people what their priorities are and be flexible and creative
Personalised care is seen as the gold standard for all service users, whether homeless or not.29 The principles of finding out what matters to the person and their priorities and then acting on that information is a good way start to develop a trusting working relationship. Allowing time may require providing double appointments. For others, providing a flexible drop-in approach can help. Easier access to care means needs that can be addressed sooner may not become severe or life threatening.30
Maximise people's capacity
Some service users have fluctuating capacity, particularly due to alcohol use. Find out what is a better time of day for the person. Be aware of the concept of executive functioning and executive capacity and that a person may be saying or agreeing to do something, but may not be able to act in a way consistent with the stated aim. Document discussions around capacity and if there is a picture of fluctuation consider safeguarding principles and referrals.
Speak to support workers
An often-unused resource for health professionals is the homeless workers from the organisations that work closely with the service users, such as street outreach teams and homeless charities. Staff in these roles are highly skilled and may have a relationship with the person spanning years that can be drawn on to facilitate engagement. However, these staff have described a bias from health professionals of discounting of their knowledge of the person.19 The staff from the homeless organisations can help in getting the right care for the person and may also be helpful in providing collateral information in addition to family and friends. Working together with professionals known to the service user is an example of the good integrated care required by all people with complex needs. ‘The Blue Light project’31 is another resource for working with treatment resistant drinkers.
Use the opportunities you are given
Given the level of exclusion and health inequality, use all opportunities of contact as effectively as possible by exploring priorities, determining ways of making contact other than letters and checking health. Share ways of engaging with service users with colleagues. Ensure registration with a GP as a point of shared care. Recognise communication issues in order to understand and to express their wishes. Lack of a home address can be a barrier to accessing care so the practical step of asking how to make contact and make appointments is essential; some homeless charities provide mobile phones.
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.
- © Royal College of Physicians 2023. All rights reserved.
References
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- National Institute for Health and Care Excellence
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- Kerslake Commission on Homelessness and Rough Sleeping
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