‘When you form silos, there are gaps, and people fall down them’

Tess: Hello, and welcome to Psyched, where we focus on the impact of psychological knowledge and research on everyday life. We're going to be talking homelessness today. Recent government statistics showed that in September 2024, around 9,000 people were estimated to be sleeping rough across England, which was up 8% on the same month of the previous year. The UK has one of the highest rates of homelessness in the developed world. And we know that most people who die on the streets die at around 44 years old, which is shocking.

Poppy: Today we've got two important guests with us in the studio. 

Tess: Loretta is a peer worker who works in hostels in the south of England, and Professor Nick Maguire is a clinical psychologist who has worked in homelessness for over 25 years. 

Thanks so much for joining us today, Loretta. Could you tell me a bit about what a peer worker is and the work that you do?

Loretta: Yeah, a peer mentor is somebody that will work across various services, with homeless people. We come with lived experience so we can identify with a lot of their needs, and act as a bridge between the services and the homeless person. 

Tess: Tell me what a usual day in the services look like for you.

Loretta: So if I do a drop in, I would go to a homeless hostel and I would speak to clients that have been referred to us and just a general chat about their wellbeing and then identify needs: for example, filling in housing forms. I can accompany them to mental health appointments or just general GP appointments and be that in-betweener. We talk a lot around relationships and the next stage of their life, and just to help navigate their way through the hostel system.

Tess: How do you think your lived experience influences the work that you do?

Loretta: I think it influences a lot, because it's much easier to confide and open up and be around people that have had similar experiences to yourself. You feel an affinity towards them straight away. And I suppose we just speak on the same level. And also everything they say is confidential, which they might necessarily not get from other people in the hostel. And we have a bit of sway… we can go in and advocate for them, which is really important. Otherwise, they may just lose their way.

Tess: You must hear a lot about people's experiences that lead to them being homeless. 

Loretta: Some of the stories are heartbreaking, I'm not going to lie. It can be from abusive childhoods to abusive relationships as they're older. It can just be a lot of people from the care system, a lot of people from the prison system, loss of housing through no fault of their own. We have been working with somebody that was a victim of cuckooing. Basically, your flat gets taken over… the council warned him, but he was being bullied by two people and unfortunately lost his council accommodation, was street homeless and then moved into the stage one hostel. 

There are so many reasons why somebody become homeless, fleeing domestic violence, drugs and alcohol. You know, you can't pay your rent. Universal credit pay rent directly now to people. So you've ultimately got a choice whether you want to spend that money on your rent or whatever substance you're addicted to. That's become a massive problem.

Tess: It's really complex, isn't it? And really challenging for people. The systems around the people that are homeless – what kind of issues do they face with those?

Loretta: I've seen people get institutionalised very, very quickly. And because there are not enough places for people to be moved on to, so stage two, which is a step down in the support. For example, in a stage one hostel, you get all your food cooked for you. You've got support on tap. It can make somebody institutionalised, helpless. 

One of the difficulties is most clients that are living in hostels, they know they've got an awfully long wait for a council property. And unfortunately, some people that get moved into a council property, they've automatically lost their community because people that live in large hostels particularly, they have a ready-made community. They don't want for any company. Unfortunately, drugs and alcohol do get brought into the hostel as well. So to thrust somebody that's not ready into their own accommodation can be extremely scary. And unfortunately, then the cycle repeats – they don't pay their rent, they continue or start using drugs or alcohol to cope with the feelings of loneliness and despair. And then they end up street homeless, and then the cycle continues.

Tess: It sounds like the work you do can be really important, but quite tough as well. How do you manage that? What's in place to support you?

Loretta: Well, I do get satisfaction when I see clients being moved on to the next stage. And also I feel a lot of satisfaction when I take people through the drug and alcohol services and they start getting off substances. You can see they look glowing. They've got a sense of purpose. There is hope to get their life back on track. And for me, I like solo traveling, where I can just go and do my own thing.

Poppy: If you don't mind me asking, I'd like to hear a bit of your back story – how you got to be a peer worker, but also some of the challenges you've been through.

Loretta: I struggled with mental health issues most of my life. I had my son very young, and I found it very hard to cope, and I was on benefits, and I started drinking socially at first, at the weekends. And then, as a lot of people know, when you start drinking a little bit more heavily, you make bad choices about the people that you let in your life. Unfortunately, I've gotten into some really bad relationships. 

Then I got a job working in a stage one hostel for about three and a half years, and I really enjoyed the work, but I just wasn't mentally prepared for what I would see or the situations that I would be in… the trauma you're dealing with, with different people on a day-to-day basis. So I had problems around child care at that time, and I left that job. I felt kind of useless then, redundant. I got into another bad relationship, and I started to drink quite heavily to the point where five years ago I was actually diagnosed with cirrhosis of the liver. Spent nearly a month in hospital, nearly died. Came out of hospital, still had a couple of relapses after that, but I knew ultimately that I'd have to stop drinking. So I went to local drug and alcohol services, made the meetings a big part of my life, and then connected really with the people that I had worked with when they were homeless. I've always had a caring nature, and I always want to see other people do well. So I thought, I'm in a better position now. I'm older, I'm wiser. I've got recovery under my belt. I've got experience. I know quite a bit about housing. This would potentially be a perfect role for me, and I'm really enjoying it.

Poppy: Thanks for sharing that. Sounds like you went through a lot, but I'm really glad that you've got the job that you have and get to care for people and do what you're good at.

Right, Nick, to you. To start off, how would you sum up your research?

Nick: At the university, we formed a centre for homelessness research and practice. And one of the really important things is that all the research that we do, and the training we do, is based in practice. It's based in and on the experiences of people like Loretta. So Loretta supports us in the kind of things we could and should be researching. 

Now, one of the things that I guess we've evolved is an understanding that homelessness is massively complex and involves a lot of layers. It's the interaction of not just individuals, but individuals within their context, within the systems around which it's conforming. So we've started to investigate those systems in terms of research, but also the individual factors around things like the experience of a mental health issue and how that's related to early childhood experience.

Poppy: And is there a difference between complex and complicated when it comes to homelessness?

Nick: It's an interesting one. Things that are complicated, you can define them. You can reduce them to component parts. A computer is complicated, but you can understand it. If you take it apart, you can understand that there's a fan and a chip and a monitor and you can even take a chip apart and understand that and look at it and understand right down to individual transistors on a microchip. But a complex problem, it doesn't yield to rational inquiry. You can't reduce it to its component parts. The more detail you look at something in, the more detail you'll see. And there are also dynamic interactions between the various component parts. There's a really useful podcast called the Cats and Clocks Podcast… try to understand a cat by taking it apart! 

So the way we've started to understand homelessness is as a whole set of layers of factors which might affect people, right from the individual level – thinking about mental health issues, and perhaps why people use substances – right up through the organisations, like the NHS or the charities which serve people, and through that to the macro system, the way in which we configure our society. That includes the stigmatised assumptions that are often made about people with homelessness, and also the way in which we configure our economy. Our economy is configured around a fairly large wealth differential, and with that we get a large health differential. You start to see where poverty, particularly child poverty, is implicated in a high wealth differential. And some of the really interesting research has found that where you get high poverty, you often get high homelessness, because people get disenfranchised from institutions like education and then employment. You see pathways through poverty into the possibilities of homelessness, which then interact with mental health issues. And you start to see why people perhaps go to other ways of coping with distress, like using alcohol or using illegal substances.

Poppy: How many people who use substances actually end up homeless? What's the steps between that and ending up without a home?

Nick: There are a myriad of pathways through to homelessness. I think opportunities come into it a lot. If you haven't got any opportunities, and the people around you haven't got any opportunities, you feel stuck. But if you are an intelligent person, or if you have got drive, you want to take away those feelings of hopelessness and being trapped – hence using drugs and alcohol.

Tess: And Loretta, you mentioned that this also impacted the types of relationships that you were having.

Loretta: Definitely. If you feel rubbish about yourself, because you're not where you want to be in life, you know that you're drinking too much or taking too many drugs, and you know the future looks bleak, then somebody shows you a bit of attention… you're more likely to go for it. Nine times out of ten, you meet somebody that's got worse issues than you, but you stay in that relationship because of loneliness, and because maybe they offer you false hope, or safety in numbers. You feel that you're in a unit.

Nick: It makes complete sense in terms of humans being social, right? We're intensely social. Relationships are going to be massively important. Loretta, earlier you were talking a bit about the hostel being a kind of community. And it might be massively dysfunctional, but it's a community. We make a lot of judgments and assumptions from a particular perspective. We think, that's a dysfunctional relationship, that's a functional relationship. But from the individual's perspective, it might not be like that. If you've got somebody that feels really low, somebody else is just breadcrumbing them, the bare minimum, they're more likely to go for it because their self-esteem and their confidence and their housing situation and their drug problem and childhood trauma, it all comes to head.

Poppy: Breadcrumbing, that's such a good word to describe it. Feeding you just enough to keep you involved. Would you say that about relationships and substances or both?

Nick: Both, I think. So the business model is about getting people addicted, just feeding them enough so that they want to come back. And the same with a relationship, somebody who wants power over somebody else will just feed them enough.

Loretta: In the homeless community, it's particularly prevalent. If you took a couple from, say, a middle class background, and they want to break up, one could go to their parents, they could get financial support, go and rent somewhere. But people in the homeless hostel, they very rarely have family or support or friends that are not in the same situation as themselves. So moving apart from that relationship is extremely difficult. Especially when drink and drugs are involved… there are manipulative people in whatever society, but I see it firsthand within the homelessness.

Tess: So, psychology has a clear role to play in terms of being able to understand some of the complexities. I wonder what that might mean in terms of any intervention work.

Nick: We think of an individual within their context, and the surrounding systems, particularly the societal institutions like the NHS, which are set up to be able to help that person to work with those things. They might be told 'you've got a substance abuse problem, but go and get your mental health sorted out first'. Or 'No, you've got a mental health problem but go and get your substance abuse problem sorted first'. The NHS is a universal healthcare system. It has to treat everybody. When your system has the responsibility of treating everybody, you start to think of efficiency in a very particular way. And efficiency starts looking like 'how many of that population can you see?' You start to privilege 'output data'. In other words, how many people have you seen throughout that day? And a lot of NHS services, not all, but a lot, will privilege that form of data. Contacts, they call it. 

Now, unfortunately, for the people we serve, there are a set of assumptions around where health takes place. And health takes place in a clinic somewhere. It could be a doctors' surgery, it could be a hospital, it could be some community mental health team, some clinic in the community. And the assumption is that people will go to that place in order to receive the benevolence of health. Now, what if actually that makes no sense to somebody whatsoever? It makes no sense to somebody to go to a clinic. In fact, it makes no sense to even think about your health at all. If you've been told that you're a piece of crap all your life, why would you think that you were a valuable person? Why would you think that you deserve the attention from any form of health system? 

So health systems understandably make a set of assumptions about how people are and why people might go for their health. But when those assumptions break down, that's where the interaction can be expressed – the interaction between the individual and the system being provided. So you get a breakdown of that system's ability to serve that person, or that person's ability to be able to access that system, which is the way we would usually frame it.

Tess: I've certainly experienced that when I was working in homelessness. There were people who could not access NHS services or would not go to appointments and so wouldn't get seen, or were told they had to work on their substance misuse problems before their mental health; and even banks that would struggle to provide accounts for people when they didn't have a static address, so they had nowhere for their benefits to be paid into. There was a lot of negotiation that needed to be done with these wider networks that just weren't set up to work with people that needed that flexibility.

Nick: And it goes wider than that. Ask yourself, why are people bounced between drugs and alcohol services and mental health services? Part of the reason is that they're commissioned separately in many areas, and neither of those providers have nearly enough resources to serve the population for whom they're trying to serve. So it becomes a rational decision – not a good decision, but a rational decision – to try and limit their exposure to things like waiting lists, and the difficulties for staff running the systems. We talk about systems, but actually people run systems. You can imagine how difficult it must be for somebody who works in any of these services to have to say 'no, I know that you're in need, but our services just don't have the resource to serve you'. 

So systems are then put in place which cause people to be excluded. 'If you're using drugs, go and get your drugs sorted out before we'll treat your mental health problems'. Now, that shows a fundamental misunderstanding of the functional relationship between mental health issues and substance use issues. The two are fused, and to try and treat the two separately and commission separate services causes problems.

These are well-known issues. We talk about the gaps, we talk about siloed care. There's a silo for drug and alcohol services, and there's a silo for mental health. But unfortunately, when you form silos, there are gaps between them, and it's down those gaps that people fall, because we haven't commissioned the services and don't deliver the services according to the needs of the population who need them most.

Tess: And I guess that's where the psychological research is so important, because you're gathering data and information to support that these things are happening and to agitate for change.

Nick: Absolutely. So, having a centre that knits together research, training and practice is really important. And the University of Southampton is very good at this. It articulates in its strategy this idea that research and training and people and enterprise should be knitted together. And that's a very good headline for us, because we're able to do that. We have research and training delivered by the university, and we also have a practice. Loretta works for a community interest company that we've been setting up. That practice element is very important in being able to feed back into the university, the training. Loretta will be involved in designing and delivering the postgraduate certificate that we're offering. And also, advising on the kind of research that we should be doing and the way in which we carry out that research. Co-creation is a massively important part of the way in which research and training happens.

Poppy: You've described your research that you've done, and I just wondered how this kind of gets put into practice, how it moves from the research rooms into the real world.

Nick: The big thing that we try and do, I think, is not serve people in silos. We try to join services up. And one of the ways we do that is we're able to offer clinical psychology trainees placements. Because they're not held to a budget, nobody owns them, they're able to work across a locale. So for example, across Southampton as a city. That means they're not confined to just working in their drug and alcohol service or just working in a hostel or just working in a mental health service. They can work with people across those services. We can help to join up the thinking around those services. 

The other way we also more directly work with systems is by actually working with their leaders, helping them to understand what drives them to behave in the way that they do. Often a commissioner of a service could be a local authority, could be a government department or whatever, often has a particular set of KPIs, key performance indicators, that the provider has to adhere to – getting people off the street, or whatever. Now, one of the things we know, and Loretta will know this, is when somebody tries to make you do something, you want to just do the opposite. So there's no point just badgering people to say, why aren't you in a hostel or why are you still using? It just doesn't work. It even works the reverse way. 

Instead, the understanding around motivational interviewing is that you talk to somebody about why they might want to change and also validate why they might not want to change. And the really interesting thing is that when you say, don't worry about KPIs, people are much more effective because they just sit with people, establish working relationships, proper working relationships, and take the time to do that. I don't know whether that's how you've experienced the work, Loretta?

Loretta: Totally. And I feel that I work really well with the Assistant Psychologists because they can talk to me about why somebody may be behaving like that, and I can relay it back to the client in appropriate language. Within the peer mentoring work, we can use our lived experience to match with a particular client to help them to understand their own feelings and thoughts and behaviour with the help of the Assistant Psychologist. So it's just brilliant. We all work together, it's not 'I'm me' and 'you are you'. It's the three of us working together, coming at it from all angles.

Tess: And it sounds like having a broader understanding of why people might be behaving in the way that they are might help services to be more compassionate towards them, and for the person to maybe be a bit more compassionate towards themselves.

Loretta: Totally… I feel that in any services, there's a hierarchy, but as a peer mentor, we are bridging that gap. We can explain to our clients in non-technical, non-medical language, the process of what's gonna happen. And from our own lived experience, we can describe the inside of a detox place or a drug and alcohol unit or a mental health unit. We can come in from somebody that's done that, that's been there themself for themself, and we can explain it in plain terms.

Poppy: That sounds like a good way of doing things. And it's great that the research that you do has led to that coming together and helping people in a way that sounds like it's working. Is this something that you have across the whole of UK, and maybe in other countries?

Nick: We set up and wrote some stuff around psychologically informed environments a few years ago, about 10-12 years ago now. And so that way of thinking psychologically about all aspects of an environment – the built environment, the systems environment, the interpersonal environment, all of those things – we can start to use psychological theory and practice in order to be able to map those things and the interactions. People start to get this way of thinking. 

We work quite closely with the Street Medicine Institute, which is a US movement. And they don't have too many psychologists, they've got a few and we've started to establish relationships with them. There are somewhere between half a million and a million people on the streets in the US. We work quite closely with some people in Los Angeles, and their team has responsibility for around 72,000 people living on the streets in Los Angeles alone. You know, this puts our problems into a bit of a context. 

We're lucky in that we have amazing assistant psychologists and trainee psychologists, which means that we can scale the way we're working. We run contracts in Southampton and Portsmouth and Bath and Basingstoke, but also sometimes we deliver teaching and training in other places. One of the big things that we've started to do is to think about how we can help the sector to be professionalised. We've got incredible staff who are often under huge strain, and we need to be supporting them. So we do spend quite a lot of time supporting people, but also supporting their staff and helping them to understand what is going on and why they're getting angry or frustrated or hopeless about what's going on.

We've started to formalise that training into a certificated training program. We've got a curriculum that Steph Barker put together. She's one of the key figures in our centre. And so we can start to think about a curriculum and helping people to build skills over time and be assessed according to those skills, which supports the professionalisation and the value of the people who work in sector already.

Poppy: It seems to me like the most important thing in helping people out of homelessness is forming a relationship with the person and taking an individualised approach. Is it sometimes difficult to form that relationship with someone who maybe has been through abuse or really hard times, or who has been isolated from society or excluded for a long period of time? Is it hard to build that trust?

Loretta: I can answer that. Whenever I meet somebody for the first time and I get introduced as a peer mentor with lived experience, you can instantly see somebody relax because they know then that actually that I've been where they have been, or I've experienced similar circumstances or things to them. 

Nick: So if I turn up as a psychologist, well, who am I? Am I to be trusted? Probably not. I'm just part of an institution that has excluded and brutalised some people throughout their lives. Why would I be any different? If Loretta turns up, that's a very different proposition, because there's the understanding there, right? 

Loretta: Totally. And there's a certain language that people in any social groups use that the other person would just say, oh yeah, I can identify with this person. It just makes that relationship form so much quicker. As soon as I open my mouth, they can tell that I can identify with them. The nuances in language, some of the sayings and stuff, it can break the ice straight away. 

Tess: Loretta, you make a good point because traditionally, clinical psychology in particular has been quite white, female and middle class. And now there is a drive, I think quite rightly, to diversify clinical psychology. That's so important in terms of representing the people that we are serving.

Loretta: Well, it doesn't matter where you come from or what you look like or where you were brought up if you've all got that common goal in the subject that you want to get into. So rather than it being a subject where it's expected you'll fit that subject, the subject should fit you.

Poppy: I've got a friend who suddenly got like ivy and like loads of brambles and stuff tattooed all over his back and his arms… I was like, 'what on earth are you doing?' And he said 'I want to be a clinical psychologist and I want to be able to connect with the people I'm working with'. And I thought, actually, that's great. Break a few assumptions.

Nick: I used to do all my clinic runs on a motorbike, turning up in leathers. I heard later, they used to call me Terminator! But it broke an assumption that somebody might have about me.

Loretta: I never make judgments about the people that I'm working with in the hostel because I've come across some amazingly intelligent people. Somebody brought their art book down to me a few months ago and I was like, wow. Different circumstances, he could have had them hanging in a gallery. Actually, I think artwork and amazing creativity comes through really hard times. 

People within the homeless sector, they are quite guarded because often when people used to speak to so many different professionals, so many members of staff, telling the story over and over again. And re-telling that story is traumatic. You don't want to be watching telly with your dinner and then you've got a session, 'go back to when you were six'. People don't want to do that. And yet the services often expect people to do that time and time again. 

Nick: Sometimes when you ask people, 'what was it about your recovery?', they might say 'there was just one key worker, and I was horrible to her. But she stuck by me, and she didn't take any of my crap. And because she was reliable, and she stuck by me, through a very difficult patch, I was able to start to think about recovery.'

Poppy: Yeah, I think it's amazing when clinicians just sit by clients, and the client doesn't expect it. They do something that they think will make the clinician go, 'right, that's it, I'm going. But no, they're like, 'it's okay. I'm still here. I'm never going to go anywhere. I'm going to help you.'

Nick: Often these people that are in these circumstances, they've been abandoned all their lives. They're abandoned by the education system, because mental illness or behaviour difficulties are not picked up, so they're just singled out as a bad kid or a troublemaker. They could be abandoned by their parents, because their parents have faced similar difficulties. And then it's just a cycle that repeats. You go straight into services with this instant mistrust of everybody. 

Tess: And, you know, in psychology, we often talk about patterns of attachment and how even early patterns of attachment and relationships can really influence later patterns as well. So understanding that it can be a long journey for some people to learn to trust people, and yet still sticking by them, is really important. And we've got an episode coming up where people are going to talk about attachment and research in attachment and what that means in terms of working with complexity. 

I just wanted to say a really big thank you to you, Loretta, and also to you, Nick. It's obviously a really important area where there's still so much work to be done supporting people who are experiencing homelessness. Thank you so much.

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