It goes without saying that homelessness and poor mental health go hand in hand. But this unhappy marriage between suffering from mental health issues and being homeless is complex, and a tough cycle to break. At the crux of this issue are the barriers preventing those without homes from receiving adequate and effective help from mental healthcare professionals.
A Mental Health Crisis
80% of the homeless population in England reported having mental health problems, of which 45% were diagnosed, according to a large health audit of over 2,500 people. According to Crisis, this indicates that homeless people are nearly twice as likely to suffer from common mental health problems as the general public.
In fact, the more serious the mental health illness, the more the gap widens between those with homes and those without: disorders like post-traumatic stress, schizophrenia, and bipolar are far more common, and suicide rates are a devastating 9 times higher (see the Homelessness Kills study).
These worrying statistics pose a question: do people become homeless because they experience mental illness, or are mental health problems the result of the traumatic and stressful experience of homelessness?
An Inescapable Cycle
The Answer is both. Poor mental health is both a cause and consequence of homelessness. The two are intertwined, and for too many people they become a cycle that is incredibly hard to break.
The causes can begin in childhood, with research showing that a relatively high number of homeless adults experienced neglect or abuse in their early years. This trauma can manifest in many mental health illnesses. Of course, mental illness isn’t always the result of external factors. But the fact is that it can destabilize someone’s life by causing changes in cognition: feeling depressed, anxious, paranoid or demotivated can make it hard to maintain stable jobs, incomes, relationships, and ultimately housing.
Likewise, the distressing experience of homelessness may trigger mental health issues: difficulty accessing safe places to sleep, food, drink, or shelter from the weather are traumatising situations. It’s also important to recognize that the treatment of the homeless, and the ways in which they are ruthlessly marginalised by society, exacerbates poor mental wellbeing. A survey by Crisis found that 61% of homeless service users classify as ‘lonely’. With loneliness comes isolation, and 53% reported that this made it harder to seek help
And so for too many, homelessness and mental illness becomes an inescapable cycle. As with loneliness, affective disorders such as depression and bipolar make it harder to seek out support from health services. But this is just one side of the story. Unfortunately, there are other barriers pushing mental health support even further out of reach.
Substance Misuse
The cruel nature of homelessness means that once someone finds themselves without a stable home, other interlocking disadvantages manifest. This is argued in a study by the LankellyChase Foundation, who refer to this as ‘severe and multiple disadvantage (SMD)’. One primary example is the link between homeless, mental health, and substance abuse. In one survey 12% of participants with a mental health diagnosis also reported issues with substance abuse.
Sadly, using drugs and alcohol to cope with the isolation of homelessness is commonplace. In turn, the debilitating effects of substance abuse creates further barriers to receiving support from health services and homeless agencies alike.
Mental Health Care Barriers
Access & Logistical Barriers
These are the practical obstructions making attending a GP appointment or collecting prescribed medication difficult for someone homeless, and they include:
Access to a charged phone to book appointments
Access to the internet to book appointments
Ability to travel to a GP surgery or pharmacy via public transport or car
Ability to keep medication secure if sleeping rough
Discrimination
But the trouble doesn’t end here. On approaching GP and mental health services, many are being refused entry by the professionals they seek help from. It is common to refuse to see someone because they:
Couldn’t provide a proof of address or identification
Have missed previous appointments
Have a drug or alcohol problem
Have serious mental health issue that is considered too “high risk”
It is shocking that there are cases where homeless people have been rejected by health services because they are presenting the very behaviours that indicate they have the greatest need for help: substance misuse, abnormal behaviour, signs of self-harm and even suicide attempts. It is reported that individuals are being told that they won’t receive support until they sort their substance misuse, by the very people who should be helping them achieve this goal.
This backward logic and lack of inclusivity is keeping people locked in an endless cycle.
Unsafe Discharge
As a result, homeless people are turning to acute/ A&E health services, with a footfall 4 times higher than the general public at a cost of £85m per year according to the Department of Health. But sadly these aren’t equipped to provide the appropriate mental health care, which requires a long-term treatment plan. Instead, individuals sleeping rough are being treated and then cast right back out onto the streets.
Alarmingly, appropriate mental health services are also discharging patients onto the streets in large numbers. This shows a complete lack of connection between health and social services, and a low sense of accountability among medical staff.
Time for Change
Taking all these factors into account, it’s no wonder that so many who find themselves homeless are facing a downward mental health spiral. This is coupled with a downward trajectory of connected physical health; from the effects of substance abuse and self-harm, to heart and nervous-system problems.
So what can be done? Numerous audits and surveys are drawing the same conclusions: we need an integrated and coordinated network of mental health, housing, and homeless support services. A joined-up approach that’s tailored to and educated in the needs of the homeless will result in easier access and more effective treatment, that sets individuals up for long-term recovery or management of mental health issues.
Access & Logistical Barriers > Tailored Services
Health services based around partnered homeless agencies.
Homeless services that notify health specialists of new users, who then screen them for problems with mental health, drugs, and alcohol.
Health care and homeless support specialists that work together to ensure that important information and documents are kept safe.
Discrimination > Inclusive Culture
Health care professionals that are educated in the needs of homeless people.
Mental health specialists like psychologists and psychotherapists assigned to address the levels of mental health problems among homeless people.
Registration offered to homeless people without presenting identification.
Flexible appointment times, and the ability of GPs to spend more time with patients.
Appointment reminders provided by the staff.
Unsafe Discharge > Holistic Aftercare
Mental health specialists to work alongside support workers and housing support staff to help treat patients and to set them up to move on afterwards.
Advice and help to be provided regarding accommodation as part of discharge and aftercare planning.
Networks of beds for the homeless who no longer require hospital care but need ongoing support, providing a safe place for treatment and recovery.
Leading the Way for Change
The good news is there are existing projects that are paving the way for inclusive and joined-up health and social services. They are helping to break the vicious cycle of homelessness and mental health deterioration, and can serve as a blueprint for a wider national plan to tailor health services to the homeless population.
Projects getting it right:
Inclusion Healthcare, Leicester
City Reach, Norfolk
Hospital Discharge Network, St Mungo’s Broadway
Two Saints’ Breathing Space, Southampton
Clothing Collective: Restoring Dignity and Control
Activities that restore a sense of dignity and control in the life of someone in poverty can have an extremely positive effect on mental health. By distributing vouchers which can be redeemed in charity shops, the Clothing Collective provides clothes for those in need in a way that allows individuals to retain their sense of autonomy and self-expression.
To help those in need, you can make donations to the Clothing Collective here
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