Homelessness and the brain

Recent research suggests that around 50 per cent of the homeless population report having sustained a traumatic brain injury, and the vast majority of those happened before a person became homeless. Many with unrecognised brain injury fall through the gaps of services, and as a result University of Liverpool academics and partners, including Headway, are moving towards developing an outreach NeuroTriage service in Liverpool to give neuropsychological assessment, intervention and follow-on support to those experiencing homelessness and a brain injury or neurological deficit.

The University of Liverpool hosted a conference exploring the area in more depth, including talks from service users themselves, to discuss what is missing from services that set out to help the homeless. Steph Grant, who was formerly homeless and suffered a traumatic brain injury (TBI) in a car accident in 1985, has turned his experience into research looking at why and how some people become homeless in Sheffield.

Grant pointed out that this population face many challenges, including stigma, constant fear and a complex benefits system that is made even harder to comprehend in the face of a TBI. He wanted to find out why people with brain injury are so likely to become homeless. Grant said the complexity of people's needs, alongside difficulties TBI sufferers have in keeping appointments, are just a handful of the challenges they face.

He found, in conversations with homeless people, that brain injuries in the homeless are often overlooked. Many people are simply marked as having challenging behaviour or being drug- or alcohol-addicted: these problems are often treated without any consideration for whether a person may have an underlying brain injury. As a result, the same people present with the same issues that may mask an underlying brain injury.

At the time of carrying out his research Grant was part of partnership working in community with TBI rehabilitation, made up of service users and survivors of brain injury. He wanted a similar approach to his qualitative study, recruiting those with lived experience of brain injury and homelessness to interview the participants in his work.

Grant and his colleagues carried out semi-structured interviews in a feasibility study, asking about how brain injuries were acquired, what treatment and follow-up support they may have received, and moving on to questions about homelessness. Working alongside academics from the University of Sheffield, the Amy Winehouse Foundation and other health workers, Grant said the analysis of these transcripts was an emotional and very difficult thing to do. 'The material blew them away – it showed them a world of brutality they never imagined existed.'

Grant said it is near-impossible to know the true extent of homelessness in a given city; people who find themselves homeless live in fear, and find very secret and hidden places to sleep. He said in dealing with city councils many put the blame onto the homeless themselves, or say that people cannot be forced to engage with services. 'What kind of answer is that? Blaming the homeless people absolves councils of responsibility to do anything for them. It's not right that people should be blamed for their own condition.'

Dr Stephen Mullin, a clinical neuropsychologist in the Leigh Infirmary Neurorehabilitation Unit, cited statistics that there is more likelihood of homeless people having seizures – around 14.5 per cent according to one study. Around 59 per cent of these are due to epilepsy and just over 40 per cent are alcohol-related. Mullin said both epilepsy and TBI are invisible conditions, and rates of both are higher in the homeless. The homeless population are also two to four times more likely to have hypertension and other cardiovascular diseases at younger ages than either the general population or low-income adults with stable housing. This could be explained by their limited access to healthy diets, which in turn can also be detrimental to cognitive functioning.

But why might TBI put someone at risk of becoming homeless? Mullin said these and other illnesses cause a wide spectrum of different problems with language, perception vision, attention, concentration, memory and difficulties with executive and emotional functioning. When coming into contact with people experiencing these difficulties many jump to conclusions: Mullin said it is vital to raise awareness about why people may behave in a certain way and what kinds of extra assistance might help them to engage with services and cope with their injuries.

Jacq Applebee, who has experience of being both homeless and in stigmatised groups, said during her time living in hostels and B&Bs she felt like she had a bullseye on her back. In a striking talk she outlined the many issues faced by homeless people from disadvantaged groups, including black and ethnic minority people, LGBT people and women. The stereotypical image we have of homeless people, Applebee said, is that of a white, male rough sleeper – however not all homeless people sleep rough, and they certainly aren't all white or male. Homeless people who are also in minority or disadvantaged groups potentially face even more danger with many facing stigma, bigotry and potentially violence, and may be less likely to seek help due to fear.

Ironically many stigmatised groups may become homeless by their very belonging to such groups. Applebee pointed to research that found almost 70 per cent of homeless, young, LGBT people were forced from their homes by disapproving families. Help for LGBT homeless people is also on the decline: an Albert Kennedy Trust report found that between 2011 and 2013 LGBT housing services dropped from 11 to 1 per cent.

The number of BAME homeless people is increasing: a government report last year stated that between 2012 and 2015 there was an increase of 21 per cent in the black population becoming homeless and 33 per cent in Asian people becoming homeless, compared with 7 per cent of the general population.

Applebee said many BAME people feel hyper-visible and more exposed to racism and bigotry. There is also a lack of good translators to help those who may not speak English. In certain cultures there is also a lot of emphasis on shame, or bringing shame on one's family, potentially leading people to hide away from society's eyes and not seek help. There is a great deal of danger for homeless women too, some of whom become homeless after suffering domestic violence. In the face of cuts to services such as women's shelters and refuges, many have no safe place to go.

Applebee recommended that the Woman and Equalities Minister should focus on domestic violence and work towards stopping the closure of refuges. Those who work with the homeless, she added, should be better trained to help those in stigmatised or minority groups and look at whether resources are being focused in the right way to help these populations.

The conference also included two workshops, one exploring old age and dementia within the homeless population, presented by clinical psychologist Sarah Butchard. The second looked at the use of person-centred approaches by Joanne Iddon and Laura Binsale – both trainee clinical psychologists.

- Read more about the NeuroTriage project in Liverpool. Find more on homelessness in our archive.