‘Mental Health & Homelessness — Time for a change to break the link?’

08.10.2021: For this week’s PIE blog, as the lead for Psychologically Informed Environments (PIE), at the national youth homeless charity; Centrepoint, I wanted to focus on two key days that are worth highlighting this Sunday 10th October 2021. The first is ‘World Mental Health Day’ (c.f. https://www.who.int/campaigns/world-mental-health-day/2021) and the second is ‘World Homelessness Day’ (c.f. http://www.worldhomelessday.org/#:~:text=World%20Homeless%20Day%2010%2F10,on%20the%2010th%20of%20October.). It might seem to those who do not work in the health and social care sector that having both awareness campaigns on the same day could lose some of the significance of each separately. However, from the perspective of a psychologically informed environment (PIE), this joint focus on one day of both these issues is actually helpful because of the known relationship between mental health and homelessness and the importance of thinking about how we need to break this link now for future generations.

The COVID-19 pandemic has had a major impact on everyone’s mental health over the past 18 months, with many of us struggling to cope with the anxiety, loss and change that this pandemic has caused. However, imagine for a moment that you didn’t have a safe place to #StayAtHome in, or a positive support network of family or friends to help you cope with the inevitable dips in your psychological well-being over this period. This has been the case for many vulnerable individuals in the UK since the start of the UK lockdown(s) and there is now increasing evidence many of these populations, including homeless young people have been disproportionally more effected (e.g. https://centrepoint.org.uk/about-us/blog/locked-out-youth-homelessness-during-and-beyond-the-covid-19-pandemic/). Despite the ‘Everyone In’ policy during the pandemic, unfortunately there have been many challenges for homeless or vulnerable young people in accessing appropriate services addressing their mental health or housing needs as services shut their doors or moved to remote access only. Consequently, taking a moment to pause this week to consider both the issues of mental health and homelessness feels importantly and timely, and more importantly can create the thinking space to develop possible solutions to these issues in the future.

A psychologically informed environment or PIE, is defined by a focus on the psychological well-being or mental health of those experiencing homelessness (c.f. Good Practice Guide: Keats et al, 2012; https://eprints.soton.ac.uk/340022/1/Good%2520practice%2520guide%2520-%2520%2520Psychologically%2520informed%2520services%2520for%2520homeless%2520people%2520.pdf). Therefore, a PIE explicitly makes the connection between mental health and homelessness because of the growing evidence of the extent and range of psychological and mental health problems amongst individuals experiencing homelessness or rough sleeping.

For example, up to 60% of adults living in hostels in England have a diagnosable personality disorder consequent of early traumatic experiences and adverse childhood experiences (ACE’s) compared to less than 10% in the general population. Moreover, rates for all other mental health disorders are significantly over-represented, at around 25–30% of those who are street homeless or in direct access hostels (Folsom et al, 2005; Rees, 2009; Cockersell, 2011; Maguire et al, 2012). Homeless Link (2014) found that 80% of homeless people in England reported that they had mental health issues, with 45% receiving a specific mental health diagnosis (c.f. https://www.homeless.org.uk/sites/default/files/site-attachments/The%20unhealthy%20state%20of%20homelessness%20FINAL.pdf). Moreover, an evidence review by the UK Department of Communities and Local Government (2012) found that the most prevalent health problems among homeless individuals were substance misuse (62.5%), mental health problems (53.7%) or a combination of the two (42.6%), which add significantly more costs to addressing the homelessness (c.f. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/7596/2200485.pdf).

Moreover, recent research that I have been involved in at Centrepoint (e.g. Krist & Miles, 2020) has highlighted that young people referred to our services in 2019 had significantly high rates of mental health issues compared to young people within a similar aged ‘normal’ population. Our study also only looked at diagnosed mental health conditions and was conducted pre the COVID-19 pandemic, so our data is likely to be an underestimation of actual prevalence due to the known difficulties that homeless young people have in accessing statutory mental health services to obtain a formal diagnosis. Nevertheless, we found that around a third of the homeless young people had a formal mental health diagnosis. Commonly, this was noted to be depression (16.2%), anxiety (14.1%) or both (31.6%). Significant substance misuse issues were also found in around a quarter of young people (26.6%), more than twice the rate of non-homeless young people (Merikangas et al, 2010). These results highlight the need for our Centrepoint Health Team to work directly with young people to support their mental health and psychological well-being as per a PIE approach (c.f. https://centrepoint.org.uk/what-we-do/health/) but also highlights the need for more preventative work with young people to intervene early to prevent the development of mental health issues. For more discussion of the impact of homelessness on young people’s mental health, please look out for Centrepoint’s latest ‘Point Made’ podcast — ‘Mental Health in an Unequal World’ made by and featuring young people from our services talking about their experiences, which will be released this Sunday (see here: https://pointmade.buzzsprout.com/1860900/9334083-mental-health-in-an-unequal-world).

Given that last week was also National Inclusion Week (c.f. see blog here: https://drhelenmiles.medium.com/are-we-inclusive-a-psychologically-informed-perspective-on-national-inclusion-week-bfc0a3063519), I think it is also important to highlight that mental health issues often disproportionately impact on other already marginalised groups (a ‘double jeopardy’ if you are also homeless). For example, a study by Hatch & Dohrenwend (2007) found that individuals from ethnic minority groups and/or lower socio-economic groups more frequently experienced traumatic experiences (including being homeless). In addition, Black people have been found to be over represented in the mental health system, more likely to have negative or adversarial pathways to care, more likely to be diagnosis with severe and enduring mental illnesses such as psychosis, and are more likely to be detained for treatment under restrictive hospital sections (Mohan et al, 2006).

There is also evidence that mental health issues and homelessness are causally interrelated. For example, mental health problems have been identified as a risk factor for becoming homeless (Shelton et al, 2009) with as many as a quarter of homeless people citing mental health problems as the reason for being homeless (Beaumont, 2011). This can be a particular issue for young people who having experienced traumatic and abusive childhoods may display emotional problems or anti-social / challenging behaviours that may increase their risk of social care placements breaking down and them becoming homeless. Other reports (e.g. https://www.feantsa.org/download/feantsa_traumaandhomelessness03073471219052946810738.pdf) also note that mental health issues can develop during periods of homelessness even when not present before. This is because being homeless can increase your risk of experiencing trauma (e.g. violent or sexual attack) and even if you are not attacked, just being homeless can be a traumatic experience because it is beyond your control and frightening, and you are likely to be disconnected from any support networks.

Because of this interrelationship between mental health and homelessness, I therefore think that it is perhaps apt that we are challenged to pause and reflect further on both this issues this weekend and moreover, the link between them. The World Health Organisation (WHO) has recently called on governments from around the world during the World Health Assembly in May 2021 to recognise the issue of mental health, and scale up quality interventions at all levels. The WHO also provide some useful resources on mental health (e.g. https://www.who.int/news-room/feature-stories/mental-well-being-resources-for-the-public), including some examples specifically for young people (https://cdn.who.int/media/docs/default-source/campaigns-and-initiatives/world-mental-health-day/2021/5_preventing_depression_during_teens_and_twenties.pdf?sfvrsn=cbd43ed8_5).

In addition, the Young Minds organisation specifically have resources and information about young people’s mental health (c.f. https://www.youngminds.org.uk/) that are both helpful in educating ourselves further about the particular mental health issues facing young people and using within our conversations with the homeless young people we support. World Homeless Day also encourages us to consider the needs of those experiencing homelessness and aims to provide opportunities for the community to get involved in responding to homelessness. You can for example see what’s happening in your local area and how to get involved via their social media page here: https://twitter.com/homelessday?lang=en).

Of course, it is one thing to raise awareness of the issues of mental health and homelessness, and the relationship between them both but another to move this from a campaign on one day of the year to a strategy for action and change across the rest of the year. This requires significant investment in time and resources from society at all levels from government policy to local or individual initiatives both in terms of prevention and treatment. We have to work together and ensure the next generation have an opportunity to #changethestory. Understanding the link between homelessness and mental health, and providing support and interventions to address both together is key. It is often not just about providing someone with a ‘roof over their head’ but is actually about addressing the causes of homelessness such as mental health as well. Here at Centrepoint, I am proud to lead the development of our psychologically informed approach in how we work with both the homeless young people referred to us as well as how we train and support our staff to address these issues. Our PIE approach ensures that we are considering the traumatic impact of homelessness and in conjunction with our Centrepoint Health Team as well as our statutory partners where possible, we are working to address both our homeless young people’s mental health and their housing needs. We are also raising awareness of these issues to work with our partners on prevention activities. This combined effort is how we will break the cycle of trauma / mental health and homelessness, and work towards our strategic objective of ending youth homelessness for the next generation — #endyouthhomelessness2037