Helping the homeless

When you see a blanket-covered body shifting uncomfortably ina doorway, hole-ridden boots protruding at one end, matted hair at the other, what do you think? That we don't have enough houses? That the person in question should get a job? Do you feel compassion or disgust?

The reality is that the filthy, dirt-poor person you're looking at may well have been abused or neglected as a child. They've no doubt been rejected time and again. They're almost certainly in bad health, physical and mental, and could be addicted to alcohol, drugs or both. If they're female, it's likely they've suffered domestic violence.

Until recently, research on homelessness was focused on economic issues and social policy. But gradually psychology and society are waking up to the psychological processes that lead many people to become homeless in the first place. Researchers are trying to pin down how people end up with nothing and how to get them back on their feet. Therapists are listening to homeless people's stories, equipping them with the skills to cope and move on.  

Who are they?

It's easy to slip into the habit of talking about homeless people as if they are a homogeneous group, but it's more complicated than that. Do we count just those sleeping rough on the street or do we also include hostel residents and so-called 'sofa surfers' – people getting by in the lounges of friends and family?

According to the latest official UK government figures released in June 2009, there are currently over 60,000 households living in temporary accommodation of one kind or another. Focusing on rough sleeping, the latest figures for England, based on counts carried out between January 2007 and June 2008 across 74 local authorities, suggest that 483 people on average sleep rough every night (87 per cent of whom are male), although this is likely to be an underestimate. Over the course of a year, London outreach teams see around 3000 different people sleeping rough at some point. People who've been in prison or the care system are at increased risk and there's a growing trend for rough sleepers to be from Central or Eastern Europe.

The plight of a family forced by poverty to leave their home is different from the story of a woman fleeing domestic abuse, or a man with a diagnosis of schizophrenia who's spent his life moving from hostel to street to hostel. This variability is made clear in a 2008 systematic review and meta-analysis of 29 surveys involving over 5500 homeless people across seven Western countries. Seena Fazel at the University of Oxford and his colleagues found huge variability in rates of mental illness and substance abuse from one study to another. Psychotic illness, for example, was prevalent at 12.7 per cent on average, but ranged from 2.8 per cent to 42.3 per cent (the latter figure derived from a British study of homeless women). Psychosis prevalence tends to be reported as higher by studies using mental health professionals to do the interviewing, whereas the opposite is the case for depression.

These figures are focused on homelessness in the West and particularly in the UK, but it's important to recognise how the picture can vary across cultures. To take just one example, Yoshihiro Okamoto compared the demographic characteristics of a homeless sample in England with a survey of rough sleepers in Nagoya, Japan – a country that only acquired a word for the homeless after World War II. Compared with the English sample, homelessness among women was virtually non-existent in the Japanese sample. Homeless people in Nagoya also tended to be older and to have been homeless for longer.

Identifying the causes of homelessness

The question of what causes homelessness in the first place has political undertones – does the blame lie with poverty and the lack of social housing or does it sit with individuals, their histories, the choices they've made? It's also an extremely difficult question to research – the itinerant nature of the homeless population makes longitudinal research problematic, and families who would normally provide historical information are often estranged or absent.

Marianne van den Bree at the University of Cardiff is one of the psychologists attempting to chart a course through these choppy research waters. Together with colleagues she's conducted in-depth interviews with 967 homeless people taking refuge in Salvation Army Centres across the UK and Ireland. One of the most striking findings was that just over a quarter reported being homeless before they were eighteen. Thirty per cent also said they'd been emotionally abused in childhood, 25 per cent said they'd been physically abused and 3 per cent sexually abused. Eighty per cent of respondents were found to have one or more substance misuse problems and almost three quarters had mental health issues.

Van den Bree also recently conducted an American study with the advantage of a longitudinal design and found similar results. Over ten thousand teenagers were interviewed in 1994 and 1995 and then followed up in 2001 by which time just over 4 per cent had experienced homelessness. The only independent significant risk factors in adolescence were family relationship quality, school adjustment problems and being a victim of violence.

'I'm realising more and more that a cascade of risk factors may precede homelessness,' van den Bree says. 'There are people who almost from birth onwards may be struggling with many adverse factors, and these can accumulate in adolescence and adult life, culminating in something as debilitating as losing your home and having to live on the street or in a shelter.'

Evidence for the pervasive detrimental effect of childhood trauma in the homeless was provided by a study, currently in press, that measured cognitive performance in 55 homeless adults in Sheffield. Graham Pluck and his colleagues found that the mean IQ for the group as a whole was well below average, at 88. Moreover, those participants who reported having suffered more childhood sexual abuse, emotional neglect and physical neglect tended to have lower IQ scores and exhibit more apathy, disinhibition and executive dysfunction, as indicated by the frontal systems behaviour scale.

A potential physiological mechanism for these chronic effects was highlighted by another recent study that involved taking saliva samples from 66 young children at an emergency shelter for families in mid-Western USA. Cutuli and colleagues found that those children who'd experienced more negative lifetime events, including witnessing violence and being separated from their parents, tended to have higher morning levels of the stress hormone cortisol. A history of more negative life events also influenced the way the children's cortisol levels were affected by a series of cognitive tests.

Breaking the cycle

For homeless people with a complex, traumatic background, the elusive goal is often not to find hostel places, it's to keep hold of them. Many are trapped in a cycle in which their aggressive behaviour or substance abuse leads them to be ejected from hostels and back onto the streets. 'Getting kicked out is another rejection,' says Dr Nick Maguire at the University of Southampton. 'It's another "life's not fair" experience, which just contributes further to the negative view they have of themselves.'

Maguire tells me about a pilot research project he ran that aimed to break this cycle. At its heart was the provision of cognitive behavioural therapy (CBT) to hostel residents. 'The theory behind this approach,' Maguire explains, 'is that most people in the homeless population, but especially repeat homeless – those in hostels or sleeping rough – will have had a difficult childhood experience, which leads them to maladaptive coping, in terms of using drink and drugs and the display of aggressive behaviours.'

Ongoing research suggests this link between childhood neglect and later substance abuse is mediated by emotional dysregulation – that is, having a quick temper, being easily upset, and not having the skills to self-sooth. Most of us who've had a safe and loving upbringing acquire the vocabulary to articulate our thoughts and feelings, we develop the skills to regulate our own emotions. By contrast, people with an abusive background turn to external ways of dealing with their emotions, including drink, drugs and self-harm.

For the CBT trial, four homeless men who'd experienced repeated tenancy breakdowns took up residence in a hostel where they received individual weekly CBT sessions with Maguire. 'The aim was to try to enable the men to use more effective strategies to deal with the world and with their emotions,' Maguire says. The hostel support staff were also given weekly supervision and trained by a psychologist in the basics of the cognitive approach. Early results were promising. Ten weeks into the project, all four of the residents had kept their places at the hostel, and all of them had reduced their thieving, violence and alcohol consumption compared with before the project.

Maguire had hoped to pursue the research further but for the moment funding is lacking. 'Housing tends to sit in the local authority remit, which is where the funding initially came from' he says, 'but they don't want to be funding what they perceive to be a health intervention. At the same time, the Department of Health don't want to fund it because they see it as the responsibility of the local authority – so the psychological care of this population often falls between the two.'

On the ground

One of the country's few dedicated psychological services for the homeless is in Leicester, headed up by Dr Suzanne Elliott. Homeless people in the city can self-refer, bypassing the need for a GP and a fixed address, and are generally offered around 15 sessions of individual or group work, with the option of returning for more after six months. 'To make the service as accessible as possible I try to meet people wherever it suits them,' says Elliott. 'I've even worked with clients on a park bench, although not recently. More often it means meeting people in their hostel or at the day centre.'

Much of Elliott's one-to-one client work is focused on establishing a trusting relationship. 'We know that a good therapeutic relationship is crucial to successful therapeutic work, but many of the people I work with have never had a reliable, stable, consistent trusting relationship with anyone,' she says. Many of Elliott's experiences chime with Maguire's work in which he helps people learn to control their emotions. 'People get referred for anger management a lot, although the anger is often more of a problem for services than for the person themselves,' Elliott says. '

Often when I meet the person, I can see that they've got every right to be angry – but it's about using that anger in the right way and trying to find a way so that it doesn't become an obstacle to being housed.'

Often the sessions involve the homeless client coming to terms with abusive experiences from the past, having them acknowledged and heard. 'If someone's been in violent relationships,' Elliott says, 'it's thinking about how this process works and learning how to identify the same situation arising again in future relationships.'

When it comes to group work, Elliott focuses on providing sessions for the 60 per cent of homeless women who have been victims of domestic violence. The groups are led by Elliott and a mental health nurse and they follow the Freedom Programme, which is based on the feminist Duluth model. 'I'd like to do more group work,' Elliott says, 'but for many homeless people it's very difficult for them to share their experiences with others. For many, their lives are so much about survival and they need to be careful about what they share about themselves. The local homeless population can feel at times like a small community – if, for example, we were running a group on anger and one person related how she was abused in the past, she might worry that someone else in the group knows her abuser.'

Other psychological services provided by Elliott and her colleagues, in a multi-disciplinary team including mental health nurses, psychiatrists and support workers, include: cognitive assessments, for example to establish whether a homeless person has memory problems or a learning disability; consultancy to local tenancy support teams, for example providing advice to staff on how to help people who are difficult to work with or who are at risk of losing their tenancy; and offering teaching and supervision to trainees from the university.

Elliott also provides advice to a residential community for people who have long-term alcohol problems and who are homeless. Recently she's been working with them to deal with local off licences who sell alcohol on credit to people who they know have alcohol problems.

Elliott says there are unique challenges to working with homeless people, particularly in relation to their transience and the frequent crises that tend to occur in their lives. 'You might start work on goals you've set together,' she says, 'and then during the six months that you're working with them, they'll have three or four crises, which means that the original goals have to be put on hold.' But despite these challenges, Elliott remains positive about her role. 'One of the things I love about working in this service', she tells me, 'is that I get to meet people from all different walks of life, who've got all sorts of histories. I never quite know who I'm going to meet next.'

Supporting the support staff

Another city with a dedicated psychological service for the homeless is Brighton. The service was set up and run for several years by psychologist Dr Vicky House before she left last year. The Brighton team provides one-to-one therapy, including CBT and motivational interviewing, for homeless people, but when House arrived there was a particular focus on supporting the staff who work with the city's homeless population.

'When I got involved in establishing the service,' House says, 'it was clear that we needed to think strategically about how our relatively small psychology resource – at that time me and three assistant psychologists – could maximise its reach and impact on a population of approximately 1500 homeless people living in hostels and other local supported housing provisions.

'In talking to service users, it became clear that the support provided by hostel staff and other housing workers was often highly valued. However, we were struck by how these workers received very little in the way of training and support to understand the psychological difficulties their clients experienced and how to work effectively with them,' House says.

As one way to promote and strengthen psychological thinking across the existing supported housing system in Brighton, House's team decided to set up a website especially for housing support workers in the city. The site provides psychologically informed guidance on how to deliver effective support, including advice on goal setting, working with distress and understanding motivation. 'The website also hosts a discussion forum where people can share good practice tips,' House says. 'Aside from the website, we also delivered training modules on understanding and enhancing motivation using motivational interviewing, and working with strengths and goals using brief solution-focused techniques. And we offered consultations to staff teams around working with clients with specific tenancy-threatening issues.'

Nick Maguire in Southampton has conducted some research on the effects of providing support to support staff –a group that he says experiences high rates of burnout but for whom routine supervision is usually lacking. 'Clinical supervision is the way that psychologists keep their morale up,' Maguire says. 'They keep sane through good supervision – talking about not only how cases are going but the impact they're having on you and being able to use the models you know from therapy within supervision. Without it, you have no opportunity to check out beliefs like "I'm just not achieving anything here", "nothing's changing", but the thing is frontline workers seldom receive supervision.'

With funding from Westminster City Council, Maguire and his colleagues investigated the benefits of providing a four-day CBT training workshop and six months of fortnightly supervision to 30 frontline staff from 17 homeless organisations in the Westminster region. Immediately after providing frontline workers with this kind of reflective supervision, and at six-month follow-up, Maguire and his colleagues observed reductions in burnout among staff, a decrease in negative beliefs about the homeless population and an increase in perceptions of effective working. 'So we think training in supervision is absolutely key to reducing burnout among staff and boosting morale,' says Maguire. 'We need to roll this out more widely.'

The future

Apart from the services in Leicester and Brighton, Elliott and House aren't aware of any other dedicated psychology services for homeless people in the country, although there are doubtless other clinical and counselling psychologists working with this population. 'It would be great to see this kind of dedicated service accessible to more people,' Elliott says. 'It would also be great if we could start up some kind of psychologists' network for people working in this area as a result of this article.'

'I think building and strengthening existing specialist professional networks would be an extremely positive development,' House agrees. 'More needs to be done to raise awareness around the psychological needs of this marginalised group; to research how best to meet these needs effectively, and how to prevent homelessness in the first place. However, I also think promoting expertise in working with social adversity, complex trauma, and marginalisation needs to extend further into mainstream mental health and social care practice.'

Meanwhile, van den Bree and her colleagues are planning a longitudinal study involving homeless Welsh teenagers. 'We haven't started yet, but we're hoping to follow them over time. We're going to be working with the charity Llamau, which has a very good track record for remaining in contact with young people and helping them over a long period.'

Maguire agrees with Elliott that it would be wonderful if this article could act as a clarion call for psychologists working in this field to come together and form a network. 'The big thing that I think is missing in this field, that I think we can bring as psychologists, is an empirical culture,' Maguire says. 'Social care settings don't have this. You just don't see randomly controlled trials. They don't ask that question "What are you trying to change with your intervention?". That's the kind of culture that psychology brings.'

Yes, psychology in the UK has come to the homelessness issue late and rather piecemeal, Maguire says, but now it's arrived it has important things to say and contribute. 'For the people you see on the streets and in hostels, it's psychology over social policy,' he says. 'This argument has been helped in recent years by the work on complex trauma, which certainly influences my thinking. It seems easy to me to formulate links between attachment, interpersonal, emotion regulation and behavioural impulsivity problems and the behaviours which lead people to become homeless. That's why it's vital that psychologists up their game in this field'.

BOX: Encouraging service take-up

A persistent difficulty for professionals working in this field is that so many homeless people choose not to take up the services that are available to them. Psychologist Julie Christian at the University of Birmingham and colleagues such as Dominic Abrams and Chris Armitage have been investigating this issue for over 16 years and their consistent finding is that psychological factors, such as feeling in control and believing a service will be useful, are far more predictive of service take-up than demographic factors, such as age and gender.

A 2002 study involving 104 people in Bridgend and Swansea, for example, found that attitudes to an outreach programme – perceiving it to be of likely benefit – was the most powerful factor predicting intentions to use the programme. Believing that friends would be using the service and perceiving the services to be easily reachable were also significant factors. 'Our research shows that deep-seated individual differences aren't based on demographics like age and gender,' says Christian, 'but that there's a lot of experiences that homeless people have that transcend those boundaries – a lot of the same kind of feelings going on for young homeless people are exactly the same as for those who are older.'

Christian says this has implications for the way homeless services are currently funded and marketed to the homeless population. Whereas services are currently targeted at a particular demographic, Christian says it's more important to think about psychological factors. Take the example of feeling in control, Christian says the right approach is 'finding ways, besides formal committees, so that people can feel as though they have control over their utilisation of a service'.
Another practical hindrance to service take-up is excessive paperwork – pen-and-paper assessments, questionnaires and opt-in systems. 'This can be a barrier to attendance due to literacy problems,' says Dr Suzanne Elliott, who heads a service in Leicester. 'Suspicion of authority figures or institutions (with paperwork denoting professional power) also discourages homeless people from engaging with services.' One way the Leicester service tries to avoid these problems, Elliott says, is to think about power in their approach to work: 'No suits and ties or heels, no jargon, and being clear about the limits of confidentiality so that people are able to make informed choices about what they disclose.'

BOX: The APA call to end homelessness

In 2009 the American Psychological Association President James Bray commissioned a Presidential Task Force report on 'Psychology's Contribution to End Homelessness', the results of which were published in February this year (see http://bit.ly/bcwl2g). Among the report's recommendations was a call for homelessness to be incorporated into graduate psychology curricula and for psychologists to educate other service providers and the public at large about the psychosocial factors associated with homelessness – including a historyof maltreatment as a child and being a victim of domestic violence. However, the report takes pains to explain that whilst people with mental illness are at increased risk of becoming homeless, the majority of homeless people in America do not have mental health issues. That said, the report also calls on psychologists to advocate at a state and federal level for homeless people to be provided with adequate mental health services, alcohol and drug rehabilitation programmes and educational opportunities. 'Through research, training, practice and advocacy, the field of psychology can make invaluable contributions toward the remediation of homelessness,' says Bray. 'The report of this task force is a call to our profession to work to end homelessness, which is a major public health concern.' 

Dr Christian Jarrett is The Psychologist's staff journalist. [email protected]

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