Mental illness

High levels of psychosis have been demonstrated in UK homeless populations over the past 70 years. Psychiatrists started to notice an excess of hospital admissions from homeless hostels, particularly for psychotic illness (Whiteley Reference Whiteley1955; Berry Reference Berry and Orwin1966). A survey of the population of the Camberwell Reception Centre in south London (Edwards Reference Edwards, Williamson and Hawker1968) found that 25% had been admitted to a mental hospital – equal to the proportion of those with alcohol problems, and a challenge to the stereotype of the homeless man as necessarily a drinker. A later survey of a Salvation Army hostel (Timms Reference Timms and Fry1989) found that around one-third of the residents had a psychotic disorder – as did a similar proportion of those seeking admission. An Oxford hostel survey (Marshall Reference Marshall1989) found that hostel residents identified by staff as having a mental health problem of some sort showed disturbed behaviour ‘not significantly different from that expected in moderately to severely handicapped psychiatric inpatients’ – and almost half had ‘scores equivalent to those in most severely handicapped inpatients’.

More recently, a larger survey (Homeless Link 2014) found that 80% of homeless people reported a mental health problem, 48% having received a diagnosis. Levels of psychosis in homeless hostels have, over the years, been around 30%. There have been no recent survey-based estimations of mental health needs in homeless populations in the UK. However, significant numbers of people with schizophrenia continue to become homeless and present to specialist ‘homeless’ services, in spite of significant contacts with generic mental health services (Timms Reference Timms and Craig2016a).

Substance misuse

Substance misuse is more common among homeless people. Of 186 000 homeless individuals (including those living in temporary accommodation) in England in 2015, approximately half also experienced substance misuse (Bramley Reference Bramley, Fitzpatrick and Edwards2015). It also seems to be more severe in those who are rough sleeping (Gill Reference Gill, Meltzer and Hinds2003). In total, 62% of homeless people assessed in 2018–2019 had a recorded drug or alcohol need (an increase from 22% in 2014–2015), with the change almost entirely due to an increase in drug use (Weal Reference Weal2020). The use of synthetic cannabinoid receptor agonists (SCRAs, or ‘spice’) is prevalent in some homeless populations (Advisory Council on the Misuse of Drugs 2019), but opiates, crack cocaine and heroin continue to be widely used and to present greater harms (Weal Reference Weal2020). In England and Wales, opiates (particularly heroin or morphine) are the substances most frequently named in the death certificates of homeless people. Such drug-related deaths increased by 55% between 2017 and 2018.

Homeless people receiving treatment for drug and alcohol problems

In 2018–2019, 9861 people who presented to drug and alcohol services in England were recorded as having ‘no fixed abode’. This is the highest number yet recorded, but presentations have not increased as sharply as the number of people sleeping rough who have drug or alcohol problems. As many as 12 000 people may be going without treatment (Weal Reference Weal2020). Engagement with such services can be difficult – one survey noted that ‘homeless people […] are often poor at attending appointments and need flexible approaches’ (Advisory Council on the Misuse of Drugs 2018). This survey also suggested that ‘hostel-based clinics, assertive outreach and other targeted approaches are effective but need extra resources’ – which are lacking. For those with coexisting mental illness and substance misuse, current UK guidance (for all, not just homeless people) is that care may be best provided in a single integrated service. Sequential models, which prioritise one disorder over the other until one is stabilised, are not recommended (Strang Reference Strang2017). And substance misuse often prevents access to mental health support (Canavan Reference Canavan, Barry and Matanov2012).

Brain injury

Cognitive impairment is underrecognised in homeless populations. A recent Canadian study suggested premature onset of cognitive impairments and accelerated cognitive ageing in homeless people. The authors cited traumatic brain injury and alcohol use as modifiable risk factors (Gicas Reference Gicas, Jones and Thornton2020). Moderate or severe traumatic brain injury appear to be 10 times more common in homeless people compared with the general population. The presence of a traumatic brain injury is associated with poorer self-reported health, higher suicidality and higher rates of contact with health services and the criminal justice system (Stubbs Reference Stubbs, Thornton and Sevick2020).

Shared antecedents

Rough sleeping, substance misuse and mental health problems have common risk factors. There is a well-documented association between multiple adverse childhood experiences (ACEs) and the likelihood of substance misuse as an adult (Advisory Council on the Misuse of Drugs 2018). Similar associations have been shown in homeless adults (Larkin Reference Larkin, Lee and Esaki2018) and in those with mental illness (Hughes Reference Hughes, Bellis and Hardcastle2017). The higher the count of ACEs, the higher the chance of experiencing three or more ‘primary disadvantage domains’, such as homelessness, poor mental health, substance misuse and interpersonal violence.

Inclusion health

This term includes a range of services and policies that aim to prevent and redress health and social inequities among vulnerable and excluded populations (Luchenski Reference Luchenski, Maguire and Aldridge2018). Five themes inform such work: equity, comorbidity, outreach, engagement and multisectoral collaborative working.

Assertive outreach

Assertive outreach services were set up to approach those with severe and enduring mental illness who do not, for whatever reason, engage well with standard services (Seymour Reference Seymour1998). The characteristics of such services are outlined in Box 3. These are similar, but not identical, to the characteristics of homeless mental health services. For example, in the UK, we have never come across a homeless mental health service where workers had a caseload of 10 or fewer. But otherwise this description seems to fit pretty well.

Classic assertive outreach seeks to engage better with those who are not doing well with an existing service. In contrast, specialist homeless services strive to engage with those who have limited or no contact with existing health or social services. Homeless populations generally have high levels of psychosis, so this has been a major focus for outreach. Homeless people with alcohol and personality problems tend to find their way to psychiatric services, those with psychosis do not (Priest Reference Priest1976). The first major task, therefore, is how to approach the potential patient. And this will depend on the level of outreach – primary, secondary or tertiary.

Accessibility

Barriers to accessibility can be geographical, temporal or cultural. A homeless person will often not be able to travel to a clinic or hospital, so a local service will clearly be more accessible. Extended opening hours or flexible appointment times may be the only way of establishing and maintaining contact – for example a homeless person may only be accessible at their sleeping site, outside normal working hours. Formality (and, sometimes, officiousness) is always off-putting. A less formal approach can help to bridge the social distance that exists between the homeless person and the service provider.

Flexibility

All services strive to be flexible, but this will be constrained by structural limitations – clinic times, availability of senior staff, set working hours, and so on. This may not matter so much for a domiciled population with some flexibility of its own and the resources to get to (sometimes geographically remote) health services. However, those who cannot travel are less likely to use services. And, as mentioned above, registering with a primary care provider is still a significant obstacle for homeless people (Burrows Reference Burrows, Edgar and Fitch2016).

Integration with other provider systems

This is often problematic. Different agencies are run from different budgets, with different priorities and targets. However, there is some evidence that more integrated services can work better – better even than ‘parallel’ services which, on paper, deliver the same component of service (McHugo Reference McHugo, Richard and Bebout2004). As already mentioned, sequential models prioritising one disorder over another until each is stabilised are not recommended (Strang Reference Strang2017). In practice, integrated services remain the exception rather than the rule, so substance misuse continues often to prevent access to mental health support (Canavan 2012). More integrated services are currently being funded by Public Health England and NHS England but have yet to be evaluated.

Generalist/multiprofessional provision

Homeless services are usually generalist in nature. Where multimorbidity is the norm and the individual usually presents with multiple needs of different kinds at a single point in time, it may not be clear which problem needs highest priority. A service provider for homeless people can incorporate other disciplines within a single team, collaborate closely with other agencies or base a range of services at a single geographical location. Importantly, the patient should not have to go from one service to another to get the help that they need. It will also usually be easier for patients to form a trusting relationship with one service rather than several.

Relationship-focused provision

Many homeless people have had poor experience with health services in the past. They may be, at best, ambivalent to the idea of engaging with any such service again. On the other hand, if the service provider can demonstrate that they are a safe and competent presence, then a fruitful relationship can be established – and this seems to improve outcomes (Chinman Reference Chinman, Rosenheck and Lam2000). The currency of this way of working is time – hence, the benefit of small caseloads.

Use of peer advocates

The use of peer advocates, also called intentional peer support (IPS), was pioneered in the USA and The Netherlands but has recently become a feature of some services in the UK (Barker Reference Barker and McGuire2017).

Continuity

The continuous-relationship model (Morse Reference Morse, Calsyn and Miller1996) describes a service that is continuous from the point of first contact, on the street or in some other homeless milieu, to the point where the individual has moved into settled accommodation and so can be safely referred to a mainstream service. This eliminates the need for changes in team as a person moves from the street to temporary accommodation and then to permanent accommodation. But it does run against the recent trend for increasingly specialist services, strung together in flow diagrams as ‘pathways’.

Relationship-building

Relationship-building is the establishment and maintenance of a trusting and meaningful relationship between outreach worker and patient. This has been described in five stages:

• • establishing contact and credibility

• • identifying people with mental illness

• • engaging

• • carrying out assessments and treatment planning

• • maintaining a longer-term, continuing service.

Practical and psychological tasks are involved when a worker establishes themselves – and their team – as a safe, helpful presence in the person's life. At first, their emphasis will be on sorting out basic, practical problems for the person, while demonstrating their reliability and safety. This is done through turning up on time, listening, not promising more that the worker or team can offer, trying to attend to the patient's priorities, as far as possible, and not meeting rejection with defensiveness or ‘retaliatory’ rejection. Other issues include:

• • the apparently paradoxical task of accommodating dependency needs, while helping the person to become more independent

• • setting clear and firm limits, while maintaining flexibility

• • acknowledging and dealing with the refusal or avoidance of assistance and treatment – without rancour or rejection (Kuhlman Reference Kuhlman1994: pp. 51–74).

Critical time intervention

A New York initiative (Susser Reference Susser, Valencia and Conover1997), critical time intervention (CTI) provided extra input for homeless people with mental illness moving from one form of accommodation to another – usually from a large night shelter to a single-room occupancy hotel. This reduced the drop-out rate from services (and nights spent homeless) by two-thirds. Gains over the control group were maintained over the 18 months following the withdrawal of the CTI service.

One might argue that this is simply good practice anyway, but doing it in a planned and structured way did seem to make a significant difference. It involved home visits, individual support, support for caregivers, and negotiation and mediation with caregivers when problems arose. Formal handovers to local agencies were negotiated and the process lasted between 7 and 9 months. Case-loads were typically held at 15 or fewer. This meant that the individual could establish a new network of dependent relationships so that the withdrawal of the original service provider, with its attendant dependencies and support, would have less impact.

Housing First

Housing First is not a specifically psychiatric intervention, although it was originated by a Canadian psychologist (Tsemberis Reference Tsemberis, Ellen and O'Flaherty2010). It turns on its head the usual approach to rehousing vulnerable and homeless individuals, where first-stage accommodation usually has to be shared and has often been of low quality – such as night shelters or hostels – and the individual has to ‘earn’ access to more independent accommodation.

It offers permanent housing, in a single step, to homeless individuals and families without any preconditions to entry, such as not drinking, accepting treatment or otherwise participating in rehabilitation or treatment regimes. Treatment goals are developed with the individual once they have moved into their accommodation. Supportive services (such as mental health, alcohol and substance misuse services) are offered to the newly housed individual, to address those problems that had initially led to their homelessness.

Psychologically informed environments

Psychologically informed environments (PIEs) are a new model of psychological service that has recently emerged from the homeless sector and the Royal College of Psychiatrists (Johnson Reference Johnson and Haigh2011). It seeks to address the high levels of psychological disturbance (not just mental illness) in the various settings in which homeless people are served and housed. And it does this by introducing psychological expertise to such environments. Both individual and group therapy are offered. Staff are encouraged to practice reflectively, with regular staff meetings with a psychologist. An online guide is available to facilitate the development of such projects (Department of Communities and Local Government 2012).

Trauma-informed care

Homeless people and those with mental health problems are both more likely to have had (often multiple) traumas early in their lives. On top of this, homelessness itself can be traumatic, and being homeless increases the risk of further victimisation and trauma. As a consequence, many homeless people find it hard to engage with services because of a lack of trust and the rekindling of previous traumatic experiences. Problems with managing emotions and adhering to social norms can create difficulties after a move to settled housing, where closer contact with other people is unavoidable. Trauma-informed care (TIC) is not a separate ‘therapy’ but seeks to embed an awareness of these issues in a range of services, from mental health to housing (Hopper Reference Hopper, Bassuk and Olivet2010).

Enhanced access to psychotherapy

The LifeWorks project in London provided psychodynamic psychotherapy services to homeless people under the umbrella of a voluntary sector housing provider (Cockersell Reference Cockersell and Cockersell2018). These services were provided in GP surgeries, offices and day centres. Accessibility was maximised by the absence of any criteria apart from the desire to come to therapeutic sessions. Outcomes seem to have been good – including reduced use of emergency services – and it even appears to be economically effective.

For people still sleeping out, or not engaged with other housing services, a ‘pre-treatment’ approach (Conolly Reference Conolly and Cockersell2018) has provided a twice-weekly drop-in service at a specialist GP surgery for homeless people. This provides the basic elements of any sort of therapy – safety, a trusting relationship, speaking the same language and establishing clear boundaries. These tentative, ‘getting to know each other’ contacts can then progress to more formal psychotherapy sessions.

Enhanced capacity assessments and compulsory admission to hospital

Most services for homeless people aim to increase access to services and reduce social exclusion, with the active participation of the individual concerned. However, these individuals sometimes refuse services offered – and thereby imperil their health, their safety and (occasionally) the safety of others. Workers are faced with a dilemma. Do they compromise the person's immediate autonomy, for instance by involuntary hospital admission? Or continue to try to promote engagement with services (Rowe Reference Rowe, Frey and Bailey2001), even when such an approach has failed over many months?

Legislation that regulates mandatory hospital admission, such as the Mental Health Act 1983, requires that signs and symptoms of mental disorder must be identified to justify such an infringement of ordinary liberties. However, outreach teams have noted that such symptoms can be hard to elicit on the street. Consequently, individuals who seem to have an obvious impairment (at least, to those who know them best) do not get the assessment and treatment they need.

One way ahead may be to change the focus from symptoms to whether the individual has the capacity (as defined in the Mental Capacity Act 2005) to make an informed choice – such as a decision to refuse services or to stay on the street. A capacity assessment can be used to assess whether a person is able, or unable, to make such a choice. It does not replace an assessment of symptoms but complements it. If capacity is compromised regarding a vital decision concerning health and well-being, this should be considered as significant evidence in the assessment for involuntary hospital admission. A consortium of agencies in London has established guidance in this area for non-medical and medical workers (Clowes Reference Clowes, Timms and Bax2017).

Assertive outreach

Assertive outreach has not been shown to be clearly advantageous for general UK community populations (Weaver Reference Weaver, Tyrer and Ritchie2003), possibly owing to lack of fidelity to the model and comparison services already having some of the characteristics of assertive outreach teams. However, the primary outcome measure of such studies was usually hospital admission. They did manage to show significant improvements in secondary measures, such as engagement. And this may well pay off in work with homeless people. A randomised study in the USA (McBride Reference McBride, Calsyn and Morse1998) found that homeless people who received assertive community treatment seemed to gain accommodation more quickly than those who received case management, out-patient treatment or services from a drop-in centre. Help with finding and maintaining housing was especially predictive of less time spent homeless.

Another US study (Lehman Reference Lehman, Dixon and Hoch1999) found that assertive community treatment for homeless people was both more cost-effective than a standard service and ‘significantly more effective in producing more days of stable housing […] at significantly lower in-patient and emergency room costs and significantly higher out-patient costs’. The balance of cost shifted from hospital to community services.

What is the effect of a specialist community team on hospital admissions?

A UK study compared hospital admissions of homeless people in Birmingham before and after the introduction of a specialist community mental health team for homeless people (Commander Reference Commander, Odell and Sashidharan1997). The number of admissions remained much the same. The team felt that they had prevented many admissions, but there was a much higher rate of compulsory admission. One possibility was that the team was identifying people with severe mental illness on the street who had previously been overlooked. The rate of follow-up post-discharge was significantly higher – but it was usually done by the homeless team itself.

Does admission to hospital help?

In spite of a therapeutic pessimism noted by many of those who work in this area, a number of small studies have demonstrated the effectiveness of psychiatric interventions in homeless populations. An early London study (Graham Reference Graham, Salton-Cox and White1999) noted such pessimism. Staff believed that ‘admission would be difficult, the psychiatric outcome poor and that people would return to the streets soon after discharge’. However, over 90% of those with psychosis were able to remain in touch with mental health teams – admittedly, the small sample (n = 12) meant that all this could be was a proof of principle. But, overall, it was a glimmer of hope in an area deemed hopeless.

Another small study (n = 24) at Bellevue Hospital in New York (Caro Reference Caro, Nardacci, Silbert, Katz, Nardacci and Sabatini1993) showed significant symptom reduction between admission and discharge from hospital. Again, the view was pessimistic: ‘Homeless people frequently make choices to refuse medication and psychotherapy, in a world where most people cannot be trusted’. This highlighted a problem that would only start to be formally addressed with the introduction of trauma-informed care (see below).

In 2016, the specialist treatment, assessment and referral team (START) in London (Timms Reference Timms and Perry2016b) looked at 37 consecutive compulsory hospital admissions from the street. A year later, 75% of those detained and treated were still in touch with psychiatric services, 70% were still in accommodation and most were now registered with a GP. Proxy measures to be sure, but significant ones. Two problems were noted. A small number of patients were admitted twice because, on the first occasion, the ward staff did not view them as being sufficiently mentally ill. The notion that homelessness is a ‘lifestyle choice’ was sometimes invoked. And, as in Birmingham, it proved difficult to refer patients on to local services.

Housing First

Effectiveness studies were built into the Housing First model from the start. These have demonstrated that, compared with a conventional rehabilitation pathway, homeless people with mental health problems who received Housing First assistance spent less time in hospital, and less time homeless, than those offered a conventional ‘ladder-type’ rehabilitation service (Gulcur Reference Gulcur, Stefancic and Shinn2003). Some concerns were voiced that the comparison services in such studies were unlike those in the UK and Europe. In Finland, their homelessness services already included supported housing and floating support – which reflected UK practice – and were already seen to be effective. They used Housing First in a niche role, replacing emergency shelter accommodation in which homeless people with complex needs had tended to stay for long periods of time. So, they used the Housing First model as an adjunct to existing effective services (Pleace Reference Pleace2017), not as a replacement for them. A recent nuanced report looking at how this works in a UK context suggests that, although it does not work for everybody, Housing First offers some advantages over more conventional models of rehousing (Pleace Reference Pleace and Bretherton2019).